hsmith67
Guru
Below is an op note for a patient that previously had 44140, 44139, and 49585 done 2 weeks prior to presenting to ED as: shocky, diaphoretic, tachycardic, hypotensive and in severe distress. CT showed free air in the abdomen and it was presumed the anastomosis had dehisced from the surgery two weeks earlier.
Below are excerpts from the op note:
As I was entering the abdomen, I anticipated to find necrotic bowel. This was not the case. There was some fluid within the abdomen, but this was not feculent in nature. It was sequestration from his dehydration in the face of acute renal failure. There was a large gush of air that escaped upon entry into the abdominal cavity. The Bookwalter retracting system was set up to provide adequate exposure for the operation. There was some reddened and slightly brown colored fluid in the right upper quadrant, the left upper quadrant and in the deep pelvis, which was evacuated by suction. Several Liters of fluid were removed from the abdominal cavity, approximately 3 to 4 L. Gross examination of the abdomen revealed that he had a markedly dilated colon, and small bowel with thickened wall. There was extensive adhesion noted between the small bowel loops, the colon and small bowels, the pelvic walls, the lateral walls within the abdomen. Some of the adhesions were bluntly lysed by gently sweeping my finger between bowel loops releasing the bowels from one another. Next, our attention was focused on mobilizing the colonic anastomosis on the left side of the abdomen. The sigmoid colon was mobilized along the line of Toldt and rolled medially, where identification of a posterior dehiscence of the colocolostomy was seen. His sigmoid colon is very redundant. The sigmoid colon looped down into the pelvis and came back up on itself, sort of like a large sigma-shape loop. This area of the colon was also mobilized and lysed from itself thus separating it. The proximal point of resection was the proximal transverse colon and the distal point of resection the left colon. Small holes were made in the mesentery of the bowels and GIA-75 cutter was used to transect the bowel. The mesentery was amputated with the Ace Harmonic Shear. The specimen was removed and passed off the table. The stumps were hemostatic. The proximal transverse colon appeared ischemic, and was resected at the level of the hepatic flexure. Next attention was turned to the pelvis, where multiple loops of small bowel were adherent to the deep pelvis itself. It was difficult to explain why the patient developed so much adhesions in such a short period of time. We went ahead and lysed the adhesions in the pelvis, releasing the small bowel into the abdominal cavity. Several serosal tears occurred during the dissection. These were repaired with 3-0 silk sutures using a Lembert stitch. We continued around to the right lower quadrant, where there were also adhesions of the small bowel to itself, the terminal ileum and cecum. We were able to lyse most of it, however, at this point it was not necessary to remove all the adhesions from the right lower quadrant because of the unstable patient. The next challenging task was to create a colostomy in the RUQ of the abdomen. The skin in the RUQ several cm from the midline was chosen. The skin was grasped with Kocher clamp. A circular incision was made around a Kocher clamp with the bovie, excising an ellipse of skin about the size of a quarter. The subcutaneous fat was dissected down to the fascia. A cruciate incision was made in the fascia and a Kelly clamp was placed through the hole, and then the site was dilated. The bowel was brought through the opening with Babcock clamps onto the surface of the skin. Two stay sutures were placed at the fascial level to hold the bowel outside of the skin on upper and lower sides of the bowel. Once secured, the abdominal cavity was then irrigated with several L of saline and evacuated by suction. We continued to lyse the rest of the adhesions in the central portion of the abdomen, the small bowel and from the colon, from the stomach as well. Once this was completed, 2 hours were spent lysing adhesions in the abdominal cavity. ....
Drains were placed and the patient was closed up.
SO..please tell me your thoughts on how to code this case. I've submitted what I thought was correct but the payer paid only 1 CPT and said quote: "be glad you got paid for that during the post op global period!"
Thanks for your input!
Hunter Smith, CPC
Below are excerpts from the op note:
As I was entering the abdomen, I anticipated to find necrotic bowel. This was not the case. There was some fluid within the abdomen, but this was not feculent in nature. It was sequestration from his dehydration in the face of acute renal failure. There was a large gush of air that escaped upon entry into the abdominal cavity. The Bookwalter retracting system was set up to provide adequate exposure for the operation. There was some reddened and slightly brown colored fluid in the right upper quadrant, the left upper quadrant and in the deep pelvis, which was evacuated by suction. Several Liters of fluid were removed from the abdominal cavity, approximately 3 to 4 L. Gross examination of the abdomen revealed that he had a markedly dilated colon, and small bowel with thickened wall. There was extensive adhesion noted between the small bowel loops, the colon and small bowels, the pelvic walls, the lateral walls within the abdomen. Some of the adhesions were bluntly lysed by gently sweeping my finger between bowel loops releasing the bowels from one another. Next, our attention was focused on mobilizing the colonic anastomosis on the left side of the abdomen. The sigmoid colon was mobilized along the line of Toldt and rolled medially, where identification of a posterior dehiscence of the colocolostomy was seen. His sigmoid colon is very redundant. The sigmoid colon looped down into the pelvis and came back up on itself, sort of like a large sigma-shape loop. This area of the colon was also mobilized and lysed from itself thus separating it. The proximal point of resection was the proximal transverse colon and the distal point of resection the left colon. Small holes were made in the mesentery of the bowels and GIA-75 cutter was used to transect the bowel. The mesentery was amputated with the Ace Harmonic Shear. The specimen was removed and passed off the table. The stumps were hemostatic. The proximal transverse colon appeared ischemic, and was resected at the level of the hepatic flexure. Next attention was turned to the pelvis, where multiple loops of small bowel were adherent to the deep pelvis itself. It was difficult to explain why the patient developed so much adhesions in such a short period of time. We went ahead and lysed the adhesions in the pelvis, releasing the small bowel into the abdominal cavity. Several serosal tears occurred during the dissection. These were repaired with 3-0 silk sutures using a Lembert stitch. We continued around to the right lower quadrant, where there were also adhesions of the small bowel to itself, the terminal ileum and cecum. We were able to lyse most of it, however, at this point it was not necessary to remove all the adhesions from the right lower quadrant because of the unstable patient. The next challenging task was to create a colostomy in the RUQ of the abdomen. The skin in the RUQ several cm from the midline was chosen. The skin was grasped with Kocher clamp. A circular incision was made around a Kocher clamp with the bovie, excising an ellipse of skin about the size of a quarter. The subcutaneous fat was dissected down to the fascia. A cruciate incision was made in the fascia and a Kelly clamp was placed through the hole, and then the site was dilated. The bowel was brought through the opening with Babcock clamps onto the surface of the skin. Two stay sutures were placed at the fascial level to hold the bowel outside of the skin on upper and lower sides of the bowel. Once secured, the abdominal cavity was then irrigated with several L of saline and evacuated by suction. We continued to lyse the rest of the adhesions in the central portion of the abdomen, the small bowel and from the colon, from the stomach as well. Once this was completed, 2 hours were spent lysing adhesions in the abdominal cavity. ....
Drains were placed and the patient was closed up.
SO..please tell me your thoughts on how to code this case. I've submitted what I thought was correct but the payer paid only 1 CPT and said quote: "be glad you got paid for that during the post op global period!"
Thanks for your input!
Hunter Smith, CPC