I am currently in a dialoge with a provider in my office regarding billing for extensive lysis of adehesions with a Roux-en Y and Hernia repair. All coding documenation I have found states that its included in the procedure. However, if documenation supports the extensive lysis of the addehsions you can bill with a modifier 22.
Can you tell me how the documentation should read for the extensive Lysis of adhesions? One of his dicated notes states: The adbdomen was surveryed for trocar injuries. None was appreciated. Second trocare was placed under laparoscopic control which was inferior along the left lateral sidewall. Through this troacar, a ligasure was placed, and the adhesions from the omentum to the anterior abdominal wall were taken down. This was done quite carefully, and the patient had additional omental adhesions to the area of an appendectomy scar. These were also taken down. Patient had some small intestine adhered to the anterior abdominal wall. This was left in situ. Taking down the adhesions required about 25 minutes of operative time. Once the adhesions were taken down, 4 other trocars were introduced under laparscopic control.
Trying to bill compliantly
Danielle
Can you tell me how the documentation should read for the extensive Lysis of adhesions? One of his dicated notes states: The adbdomen was surveryed for trocar injuries. None was appreciated. Second trocare was placed under laparoscopic control which was inferior along the left lateral sidewall. Through this troacar, a ligasure was placed, and the adhesions from the omentum to the anterior abdominal wall were taken down. This was done quite carefully, and the patient had additional omental adhesions to the area of an appendectomy scar. These were also taken down. Patient had some small intestine adhered to the anterior abdominal wall. This was left in situ. Taking down the adhesions required about 25 minutes of operative time. Once the adhesions were taken down, 4 other trocars were introduced under laparscopic control.
Trying to bill compliantly
Danielle