Wiki Difficult colon surgery, any help would be great!!!!!!

Coastal Coder

Salem, VA
Best answers
I have copied the op report below and I am afraid I am missing something in my choice of codes. I know I can't charge for the lysis of adhesions or the hernia repair. I am coming up with 44146 with a modifier 22. Colon surgery is confusing to me at times.

Thanks in advance for the help

Open colectomy with coloproctostomy, extensive lysis of adhesions, removal of abdominal wall mesh and primary repair of recurrent ventral incisional hernia.

The patient who has a complex abdominal surgery history. He recently presented with rectal bleeding and on colonoscopy was found to have a large colon cancer just above the pelvis. He has a history of diverticulitis with sigmoid colectomy and colostomy. He subsequently underwent takedown of his colostomy and subsequent to that, had an extensive ventral incisional hernia repair with mesh implantation.
He also has a history of coronary artery disease and underwent coronary stent placement several months ago. The risks, benefits and alternatives to the proposed surgery were explained in detail to the patient and his wife. They expressed understanding and would like to proceed.

Extensive scar and adhesions from multiple prior surgeries particularly perforated diverticulitis. The colon
cancer was bulky and was located in what would have been described as the sigmoid colon in location. There was intense inflammatory response around the tumor probably from prior diverticulitis and prior surgeries. The large piece of dual mesh was removed because of the nature of this procedure and the hernias were repaired primarily during closure of the abdomen. A diverting loop ileostomy was performed because of the intense inflammatory response in the pelvis.

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The patient was brought to the operating room, and a general anesthetic was placed. He was placed in low lithotomy on the Yellofin's. His abdomen was clipped, prepped, and draped in the usual sterile fashion. A long midline incision was made eventually reaching nearly up to the xiphoid and extending down to his pubis. The piece of dual mesh was encountered immediately after incising the midline fascia. This was a piece of dual mesh placed in the past with metallic corkscrews. The mesh was not well incorporated as expected and it was, therefore, removed because of the nature of this procedure. An extensive dissection around to the piece of
dual mesh was undertaken removing not only the mesh but the metallic corkscrews. This left multiple recurrent hernias of the abdominal wall which would be repaired at the end of the procedure. Upon entering the abdomen and particularly the pelvis there was an intense scarring and inflammatory response which appeared to be mostly due to prior episodes of diverticulitis and infection within the abdomen as well as from prior laparotomy and there was a bulky tumor mass at the location which would be described as the sigmoid colon although this was removed during her prior surgery
Nevertheless it was in the sigmoid location. The left colon was mobilized medially. The left ureter was identified. It was followed down into the pelvis and was meticulously dissected away from the inflammation and scar and tumor mass. At first both the left and right ureters were thought to be involved with the tumor but after several hours of meticulous dissection they
were able to be freed up from the mass and did not appear to be involved with tumor. Similarly the tumor abutted the back side of the bladder and initial impression were that it was invading the bladder. The cautery was used to divide part of the
the bladder wall but only a small amount of its muscle fibers were removed and the remainder of the bladder appeared to be free of any tumor. The inside of the bladder was not entered. Continued meticulous dissection was performed down deep into the pelvis distal to the tumor. The proximal colon was divided with a green load on the Contour stapler. The mesentery was taken down as well with blue loads on the Contour stapler.
Further dissection deep in the pelvis was performed to get distal to the tumor and the rectal wall was divided with a green load on the Contour stapler. The remaining rectal mesentery was divided as well with cautery and Vicryl sutures. The specimen was removed from the field. It was opened on the side table. There was
quite adequate proximal and distal margins. There was no obvious metastatic disease encountered during this
exploration. The lymph node status around the tumor was suspicious on the CT scan but due to the intense scarring it was impossible to tell whether these were malignant or benign. The 31 EEA stapler was used for a low coloproctostomy. The anvil was placed in the proximal colon and sutured with a Prolene suture. The stapler was easily brought up to the rectal stump to the staple line. The stapler was fired and removed. Because of the thick nature of the colon in these locations the entire anterior wall of the anastomosis was oversewn with interrupted silk sutures. For this reason it was decided to perform a diverting loop ileostomy to protect the local proctostomy. A quarter size piece of skin was removed from the right lower quadrant and a plug of subcutaneous tissues was removed. Cruciate incisions were made in the anterior and posterior rectus sheaths. A loop of distal ileum was brought through this and an ostomy bar was applied. The pelvis was generously irrigated. Hemostasis was apparent. A Jackson-Pratt drain was placed in the pelvis and exited through a separate stab wound in the left lower quadrant. This was held into position with a nylon suture. The long midline incision was then closed and several hernia defects in this location were repaired primarily with running PDS. The fascial edges were delineated around these hernias to get back to what appeared to be strong fascia. The skin was loosely approximated with staples. Sterile dressing was applied. The ileostomy was matured in a Brooke fashion and an ostomy appliance was placed. The patient tolerated this procedure well. He was withdrawn from general anesthesia, extubated, and brought to recovery in good condition.
Since it was a low pelvic anastomosis you can't charge for the ileostomy.
44146 is for one with a colostomy. The note says diverting loop ileostomy created in the RLQ. Jackson Pratt drain was put in the LLQ.
The others codes you can add the 44310 for the ileostomy but it is bundled with the 44145.