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CPT code for insufflation - PROCEDURE PERFORMED

maybabysgirl

Contributor
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Location
Kennesaw, Georgia
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PROCEDURE PERFORMED:
1. Exploratory laparotomy.
2. Aspiration of ascites.
3. Radical debulking with removal of the uterus, cervix, ovaries, fallopian
tubes, pelvic mass and omental biopsy, along with insufflation of the
rectum .

Hi all,

The above procedures were done on a patient. I have all, but the CPT code for the insufflation of the rectum. Is there such a code? I have checked to books and online. What comes up is 0184T, that speaks of excision of rectal tumors. In this case, the doctor did not remove any tumors. It was done to make sure there were no punctures and/or incisions made to the intestine inadvertantly during the Robotic procedure.

Could someone please help me locate the correct code, if there is one?

Thank you in advance,

Dee
 

nrichard

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Location
Pensacola, Fl
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Since you haven't typed the operative report, I can only tell you what direction I would go in. I would go with a diagnostic scope procedure, or a diagnostic anaoscopy procedure. It really depends on the method used for examination and the depth of the procedure. The reason I would use the diagnostic procedure is because there Is no code for this, and really what the doctor is doing is a visual examination. I would imagine since the insuflation would be needed to visualize the area, if there were a code for this it would be bundled.
(This is the biggy) If he did the visual examination by the same approach as performed the other components of the surgery, I'm thinking examination of the rectum would be standard and not separately billable. Again this is my educated guess, since I don't have the op-note in front of me.
 

maybabysgirl

Contributor
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Location
Kennesaw, Georgia
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0
Copy of op report

INDICATIONS FOR PROCEDURE: The patient is a who
presented with pelvic pain and abdominal pain. She underwent imaging that
revealed 25-cm pelvic mass, thought to be possibly adnexal. She was brought to
the operating room today for definitive surgical management. I informed her of
the risks of the procedure, including but not limited to, infection, bleeding,
the need for transfusion, damage to bowel, bladder, vessels or ureters, deep
venous thrombosis, pulmonary embolism, complications from anesthesia, death, and
the need for additional therapy. At the end of the surgery, there was small
amount of capsule noted over the left iliac vessels.

FINDINGS: The external genitalia was atrophic. There were no gross
abnormalities noted in the vagina. There was a large palpable pelvic mass
extending above the umbilicus. Intraoperatively, the mass was adherent to the
large bowel, small bowel, bladder peritoneum and sidewalls bilaterally, in
addition to the omentum. The uterus appeared normal as did the right adnexa,
and the mass appeared to be possibly extending from the left adnexa. The
omentum was also indurated. The peritoneal surfaces in the upper abdomen along
with the stomach, spleen, liver, pancreas and stomach were all palpated and were
grossly normal

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room,
intubated without complication, placed in the dorsal lithotomy position. She
was prepped and draped in the sterile fashion. A Foley catheter placed for
intraoperative urinary drainage. A vertical midline incision was made with use
of a scalpel and carried down to obtain tissue with the use of electrocautery.
There was subcutaneous edema noted. The peritoneum was and tented and entered,
ascites was aspirated. The peritoneum was then extended cephalad and caudad. A
Bookwalter retractor was placed along with lateral sidewall retractors, and mass
was noted to be adherent to the bladder peritoneum, the rectosigmoid and the
small bowel. There was also what appeared to be a large mass extending from the
left adnexa with no definitive ovary or fallopian tube noted on the left side.
The adhesions were sharply first dissected from the bladder. The rectosigmoid
and small bowel was then sharply dissected from the posterior portion of the
mass. Once the mass was freed from the right pelvic sidewall, the uterus was
identified. It was normal size. The right adnexa appeared grossly normal. A
Kocher clamp was placed on the right adnexa. Dissection was then carried
inferiorly and posteriorly around the uterus, attempting to free the
rectosigmoid from the posterior portion of the uterus and the cervix. A Kocher
was then left cornua, while the round ligaments were cauterized and transected.
The peritoneum was extended cephalad and caudad on the right. The ureter was
identified and high above of the ureter, the infundibulopelvic ligament was
triply cauterized and transected. The omentum that was adherent to the superior
portion of the mass was sharply dissected and the portion that was adherent was
removed for pathologic evaluation with the use of a Caimin. The mass was then
sharply dissected from the rectosigmoid on the left and the pelvic sidewall. I
was unable to identify any abnormal anatomy on that side. Given that, the
bladder reflection was created from the lateral portion of the uterus, and
dissected off the lower uterine segment sharply, first on the right. The
uterine artery was clamped, cut, and suture ligated. Then with a series of
clamping, cutting and ligating, the cardinal and uterosacral ligaments were
transected. On the right, a curved clamp was placed across the vagina, and the
cervix was amputated at that point.

Attention was then turned back to the left. The iliac vessels were identified.
The mass was extensive, approximately 20 cm extending from the left adnexa. A
portion of that was removed for pathologic evaluation consistent with a low
grade spindle cell tumor. At this point, the bulk of the mass was removed for
pathologic evaluation, and the utero-ovarian ligament was clamped, cut and
suture ligated. At this point, the uterine artery was clamped, cut and suture
ligated and with a series of clamping, cutting and ligating, the remaining
cardinal uterosacral ligament was transected. A curved clamp was placed across
the vagina and the uterus and cervix were amputated for pathologic evaluation.
The vagina was then reapproximated in figure-of-eight fashion with 0-Vicryl
suture, and attention was then turned to remove the remaining portion of the
mass from the left pelvic sidewall. At this point, normal saline was placed in
the pelvis. The rectum was then insufflated. There was no gross leak noted
into the abdominal cavity. Surgicel along with Arixtra was placed over denuded
surfaces and #10 Jackson-Pratt drain was placed in the pelvis. All the
instruments, laps and sponges were removed from the patient's abdomen. There
was no active bleeding noted. The fascia was then closed in the superior and
inferior portion of the incision after the bowel was allowed to fall into its
correct anatomical position, and the suture was tied in the middle.
Subcutaneous tissue was irrigated copiously with normal saline. The dead space
was obliterated and the skin was then reapproximated in a subcuticular fashion
with 3-0 Monopril. Benzoin, Steri-Strips and a pressure dressing were applied.
The patient tolerated the procedure well. Counts were correct x2.

COMPLICATIONS: None acutely.

SPECIMENS: Ascites, omentum, pelvic mass, uterus, cervix and right adnexa.

DISPOSITION: The patient was taken to the SINI in guarded condition. I had an
extensive discussion with the patient's son, and family and friends, in
reference to the guarded state and the extent of surgery.



PROCEDURE AND FINDINGS: External Genitalia: The external genitalia were
atrophic. There were no gross abnormalities noted in the vagina. There was a
large palpable pelvic mass extending above the umbilicus. Intraoperatively, the
mass was adherent to the large bowel, small bowel, bladder, peritoneum and
sidewalls bilaterally in addition to the omentum. The uterus appeared normal as
did the right adnexa and the mass appeared to be possibly extending from the
left adnexa. The omentum as also indurated. The peritoneal surfaces in the
upper abdomen along with the stomach, spleen, liver, pancreas and stomach were
all palpated and were grossly normal.
 
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