I am NEW to this type of coding and have a physician trying to bill for a diagnostic laparoscopy, lysis of adhesions 30mi, and peg replacement and a EGD separately on the same day. Due to so many things being done I am confused as to where to begin and need guidance, any help would be appreciated. (43246? 44180? modifier 22?)
OP NOTE:
THis is a pt who presents with a malpositioned percutaneous endoluminal gastrostomy tube. The PEG was removed. It was felt that a Diagnostic laparoscopy with drainage of any possible fluid collection or infection, followed by a laparascopic-assisted peg tube placement for optimal localization was required.
A left lower quadrant 5mm optiview port was placed under direct laparoscopic vision without incident. The abdomen was insufflated. Inspection found there to be omental adhesions to the midline. I could not see the stomach. Additonal ports were placed, one in the infraumbilical midline and one in the right mid abdomen. I still could not see the stomach. I began taking down the omental adhesions with a Ligasure device. There began to be induration,edema, and edema fluid, but no discrete abscess was found.
This was irrigated and lysis of adhesions continued until I found the stomach attached to the anterior abdominal wall the place of the recent PEG.
After adhesiolysis was complete, I performed an upper endoscopy. The flexible fiberoptic gastroscope was inserted through the cricopharyngeus under direct laryngoscopy vision. The old PEG site was recannulated. This was done under direct visualization with the laparoscope as well. This was complete contained and contiguous with the anterior abdominal wall. The introducer needle was inserted and through this, a guide wire was inserted and brought out through the anterior abdominal wall to 4 cm at the skin. Direct laparascopy revealed no gaps. with insufflation, there was no aditonal leaking from the stomach.
OP NOTE:
THis is a pt who presents with a malpositioned percutaneous endoluminal gastrostomy tube. The PEG was removed. It was felt that a Diagnostic laparoscopy with drainage of any possible fluid collection or infection, followed by a laparascopic-assisted peg tube placement for optimal localization was required.
A left lower quadrant 5mm optiview port was placed under direct laparoscopic vision without incident. The abdomen was insufflated. Inspection found there to be omental adhesions to the midline. I could not see the stomach. Additonal ports were placed, one in the infraumbilical midline and one in the right mid abdomen. I still could not see the stomach. I began taking down the omental adhesions with a Ligasure device. There began to be induration,edema, and edema fluid, but no discrete abscess was found.
This was irrigated and lysis of adhesions continued until I found the stomach attached to the anterior abdominal wall the place of the recent PEG.
After adhesiolysis was complete, I performed an upper endoscopy. The flexible fiberoptic gastroscope was inserted through the cricopharyngeus under direct laryngoscopy vision. The old PEG site was recannulated. This was done under direct visualization with the laparoscope as well. This was complete contained and contiguous with the anterior abdominal wall. The introducer needle was inserted and through this, a guide wire was inserted and brought out through the anterior abdominal wall to 4 cm at the skin. Direct laparascopy revealed no gaps. with insufflation, there was no aditonal leaking from the stomach.
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