Excision of abdominal wall mass with complex closure with mesh

hedmiston

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I need help coding the complex closure of the following op report.
The surgeon wants to bill 22905, 76998, 49560, 49568 & 47100. I don't agree with 49560 & 49568. I would bill 13101 & 13102 but, I read in the Medicare policy manual: Wound repair codes 12001-13153 should not be reported separately to describe closure of the surgical incisions.
Am I on the right track? Any help would be greatly appreciated.

Pre/postoperative dx: Abdominal wall scar adenocarcinoma

Procedure Performed: Wide local excision of an epigastric abdominal wall mass using intraoperative ultrasound, liver wedge biopsies, and complex closure of the remaining ventral abdominal wall defect (incisional hernia) with a 15 x 15 cm Parietex mesh.

Findings: Intraoperative ultrasound was used to mark out an approximately 4 x 4 x 5 cm epigastric abdominal wall mass that was hypoechoic and irregular with posterior acoustic shadowing. The lesion was located at the site of a prior laparoscopic cholecystectomy epigastric port site and was notably firm and fixed extending to the peritoneum and invading the falciform ligament. Resection of the skin, subcutaneous tissue, fascia, and rectus abdominus musculature was required. Two white plaques on hepatic segment 4B were excised using wedge biopsies.

Description:An ultrasound was first performed. The abdomen was palpated, and there was noted to be the firm approximately 4 cm mass in the epigastric anterior abdominal wall. Intraoperative US was performed , and there was noted to be a heterogeneous hypoechoic irregular mass in the anterior abdominal wass with posterior acoustic shadowing extending through the abdominal wall. The US was used to mark wide margins around the mass to guide the incision and skin flaps during surgery.

An 8 mm elliptical skin incision was made in the midline vertically using the 10 blade scalpel with inclusion of the previous transverse port site scar. The incision was further deepened through the dermis and superficial subcutaneous tissue using electrocautery. Next, circumferential skin flaps were elevated. The skin flaps were elevated circumferentially to allow for adequate wide margins around the mass. The mass was periodically palpated to reoprient the skin flaps as well as to ensure that the adequate margins were obtained. In addition, care was taken to ensure that the skin flaps were thin enough to allow for an approximately 2 cm anterior as well. Once the skin flaps were elevated circumferentially enough to allow for a 2-3 cm margin circumferentially, electrocautery was used to dissect through the underlying subcutaneous tissue to the level of the fascia circumferentially. Next, electrocautery was used to dissect through the muscle and posterior rectus sheath, allowing for entrance into the abdominal cavity at a point along the inferior incision. Ligasure device was used to circumferentially dissect through the fascia, muscle, and posterior rectus sheath, again along the incision line that would allow for adequate 2-3 cm margins circumferentially from the mass.The undersurface of the peritoneum was palpated, and the mass was appreciated, but there was no extension past the level of the peritoneum. The mass did invade the Falciform Ligament, which was transected. There was no involvement of viscera. Once the mass had been circumferentially excised with inclusion of the anterior and posterior rectus sheath and muscle, the specimen was removed, and a short stitch was placed superiorly, a long stitch was left lateral, and a loop stitch along the falciform.

Abdominal cavity was examined with specific attention to the liver. There were 2 small lesions noted on the Segment IVB superior surface. Wedge biopsies were performed using electrocautery. Electrocautery was used to obtain hemostasis at the biopsy sites. There was noted to be a 2-3 mm epigastric nodule, and this was excised and sen for pathology as well. Abdominal cavity was irrigated and attention turned towards closure of the remaining abdominal wall defect.

A ruler was used to measure the remaining abdominal wall defect at approximatley 13-15 cm x 13-15 cm. Consequently, a 15 x 15 cm Parietex mesh was chosen to close the defect. First, six circumferential 2-0 prolene sutures were placed a the 12, 2, 3, 5, 6, 8, 9 and 10 o'clock positions. These sutures were all tied down and secured to the mesh. The mesh marked to orient the anterior and posterior sides with care taken to ensure that the posterior side would be shiny visceral side. The mesh was then placed in an underlay position underneath the fascia, and the corresponding spots for the sutures were marked circumferentially on the skin. The sutures were secured transfascially. After all sutures were pulled up through the skin circumferentially, they were tied down, securing the mesh in place for the underlay aspect. 2-0 Prolene sutures were used to secure the mesh to the anterior sheath for an additional inlay securement of the mesh. 3 Prolene sutures were used to secure the mesh in a running fashion. The mesh was examined and in good placement with good coverage and overlap of the abdominal wall defect.

Wound was then irrigated, and Scarpa fascia was cloed with 3-0 Vicryl interrupted Vicryl sutures. The skin was closed with a 4-0 Vicryl running subcuticular stitch. The midline incision and the stab site incision of the suture were all dressed with Dermabond, and the drapes were removed.
 

syllingk

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why can't you bill the closure? I disagree. You are not biling the hernia repair which would exclude the closure but under the m/s code it says excludes complex repair, which means it is separately reportable.
 

hedmiston

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Coding w/out liver bx?

Thanks so much! How would you code this scenerio without a liver biopsy?
Medicare vs. non Medicare patient?
*(Medicare policy manual: Wound repair codes 12001-13153 should not be reported separately to describe closure of the surgical incisions.)
 

vivekveevin

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i have doubt on above procedure hernia repair with mesh placement.47100 and 22905 are not include the mesh placement. can we code the hernia repair with mesh placement code

V.Vivek CPC
 

vivekveevin

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vivekveevin

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vivekveevin

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vivekveevin

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SharonCollachi

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A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of the tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied and three screws and the harvested bone graft were packed into the fracture site. What are the correct codes for this diagnosis and procedure?

These look like test questions.
 
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