mony94803
Contributor
I need help with coding the below encounter.
Abd was prpped and draped in a usual sterile fashion we explored the patient through his previous midline laparotomy incision with careful attention to the presence of 3 separate fistuous openings. On initally attempting to enter the adminal cavity we encountered a ver large piece of Prolene mesh which was carfully divided along its middle portion allowing us to then carefully enter the abdominal cavity where we encountered multiple areas of dense intraabdominal adhesions both between loops of bowel and loops of bowel adherent to the anterior abd wall and prevously placed mesh. After a painstaking , tedious, and technically challengin dissection that lasted a couple of hours, we were able to ultimately free all loops of the samll bowel and solid organs from the anterior abd wall. Note, pt previous placement of ver large piece of mesh that measured approx 30x40cm which extended between the bilat pericolic gutters. Once this had been divided and the adhistionslysed, we then carfully lysed multiple interloop adhisions such that we could run the bowel from the ligament of Treitz to the ileocecal valve. Not when entering the abd cavity we encountered a area along the lower 1/3 of the wound where there were no less than 4 separate layers of mesh, most of which were prolene but some appeard to ba Gore-Tex that was grossly infected and quite malodorous. A sample of pus from this area was sent for STAT Gram stain which revealed multiple gram-positive cocci and multple gram-neg rods. Having lysed all the adhesions, our attention then turned to careful exploration of the abdominal contents were we identified 1 area where there was a clear fistulous opening and that would require resection. In additon, there was a small enterotomy which was repaired in 2 layers with an inner layer of 4-0 Maxon and an outer layer of 4-0 silk lemberts. This enterotomy itself measured approx 6-7mm in length. In order to remove the 1 gross fistulous opening in the bowel we resected approx 15cm of distal jejunum utilizing multple firings of EndoGIA 60mm stapling device with 3.5mm staples applied both proximal and distal to the affected area with the associated mesentery divided with multiple applications of LigaSure Atlas device. We reestablished intestional continuity, performing a side to side with functional end to end stapled anastomosis with another firing of an EndoGiA 60mm stapling device with 3.5mm staples, closing the enterotom sites for introduction of the sapling device with a running 4-0 Maxon suture reinforced with interrupted 4-0 silk Lembert sutures. At conclusion of the procedure it was obvious that the pateint had had 3 prior small bowel resections, all of the anastomoses were intact. However, 1 was associated with chronic cavity coated with chronic granulation tissue that was adjacent to the area of gross fecal contamination of mesh leading us to believe that there had been a anastomtoc leak that had seeded the mesh to cause this chronic infection.
In addition, when lysing the adhesions we identified 1 loop of small bowel that was densley adherent tot he anterior wall through which there was a clear piece of Prolene suter material that was exiting the adominal wall surface. This was taken down, the suture removed, and there was no injury to the bowel sufficient to require its removal.
Having resected the fistual site and cored out the fistulae at the level of subcutaneous tissue, we then explanted the mesh in its entirety and sent to pathology. With the mesh explanted, we then itdentified and dissected the fascial border with ta rim of at least 4-6 cm anteriorly which allowed us to then define the fascial defect which measured approx 25x18cm wich was then closed utilizing a 13x 25cm piece of SurgiMend. We were able to reduc the transverse dimension of the fascial defect from 18 to approx 10cm given the laxity of the patients anterior abd wall. We deployed a SurgiMend biologic prosthetic which is fetal bovine dermins in an underlay manner ultiizing a series of interrupted #1 prolene sutures in a horizontal mattress orientation. The mesh lay quite nicely at the conclusion of the repair under no tension with no wrinkling. Consequently there was sufficient laxity in the anteror abd wall musculature to allow us to then close the fascial border along the midline with series of fracture or dislocation #1 Prolen sutures. This was done no to buttress the repair but to place soft tissue separation between the underlying biologic prosthetic and the subcutaneous wound. Once this was completed, two 19 French Blake drains were placed in the subcutanous space, brought out through stab wounds in the right and left lower quadrants, stablized to the level of skin with 2-0 nylon sutures, and thenthe subcutanous tissues was further reapproximated with interrupted 3-0 polysorb sutures before deploying a delayed primary closure dessing which consisited of Xerform in the subcutaneous space, approx 10 vertical mattress 3-0 nylon sutures that were placed but not tied, and then a sertile gauze dressing placed over the midline incision. Prior to deploying the delayed primary closure, excess skin was excised from the midline wound along with excision of much of the old scar and association inflammation from the chronic fistulous tractss. Patient tolerated procdure quite well.
This was coded as:
44120
49402-51
49565-59
13101-59
15330-51
49568
13102 x4
15331 x2
Is that correct? I didn't see that any hernia repairs were performed and don't know if we can code the layered closures separatley? Can anyone please help?
Thanks
Simone Shofner CPC
Abd was prpped and draped in a usual sterile fashion we explored the patient through his previous midline laparotomy incision with careful attention to the presence of 3 separate fistuous openings. On initally attempting to enter the adminal cavity we encountered a ver large piece of Prolene mesh which was carfully divided along its middle portion allowing us to then carefully enter the abdominal cavity where we encountered multiple areas of dense intraabdominal adhesions both between loops of bowel and loops of bowel adherent to the anterior abd wall and prevously placed mesh. After a painstaking , tedious, and technically challengin dissection that lasted a couple of hours, we were able to ultimately free all loops of the samll bowel and solid organs from the anterior abd wall. Note, pt previous placement of ver large piece of mesh that measured approx 30x40cm which extended between the bilat pericolic gutters. Once this had been divided and the adhistionslysed, we then carfully lysed multiple interloop adhisions such that we could run the bowel from the ligament of Treitz to the ileocecal valve. Not when entering the abd cavity we encountered a area along the lower 1/3 of the wound where there were no less than 4 separate layers of mesh, most of which were prolene but some appeard to ba Gore-Tex that was grossly infected and quite malodorous. A sample of pus from this area was sent for STAT Gram stain which revealed multiple gram-positive cocci and multple gram-neg rods. Having lysed all the adhesions, our attention then turned to careful exploration of the abdominal contents were we identified 1 area where there was a clear fistulous opening and that would require resection. In additon, there was a small enterotomy which was repaired in 2 layers with an inner layer of 4-0 Maxon and an outer layer of 4-0 silk lemberts. This enterotomy itself measured approx 6-7mm in length. In order to remove the 1 gross fistulous opening in the bowel we resected approx 15cm of distal jejunum utilizing multple firings of EndoGIA 60mm stapling device with 3.5mm staples applied both proximal and distal to the affected area with the associated mesentery divided with multiple applications of LigaSure Atlas device. We reestablished intestional continuity, performing a side to side with functional end to end stapled anastomosis with another firing of an EndoGiA 60mm stapling device with 3.5mm staples, closing the enterotom sites for introduction of the sapling device with a running 4-0 Maxon suture reinforced with interrupted 4-0 silk Lembert sutures. At conclusion of the procedure it was obvious that the pateint had had 3 prior small bowel resections, all of the anastomoses were intact. However, 1 was associated with chronic cavity coated with chronic granulation tissue that was adjacent to the area of gross fecal contamination of mesh leading us to believe that there had been a anastomtoc leak that had seeded the mesh to cause this chronic infection.
In addition, when lysing the adhesions we identified 1 loop of small bowel that was densley adherent tot he anterior wall through which there was a clear piece of Prolene suter material that was exiting the adominal wall surface. This was taken down, the suture removed, and there was no injury to the bowel sufficient to require its removal.
Having resected the fistual site and cored out the fistulae at the level of subcutaneous tissue, we then explanted the mesh in its entirety and sent to pathology. With the mesh explanted, we then itdentified and dissected the fascial border with ta rim of at least 4-6 cm anteriorly which allowed us to then define the fascial defect which measured approx 25x18cm wich was then closed utilizing a 13x 25cm piece of SurgiMend. We were able to reduc the transverse dimension of the fascial defect from 18 to approx 10cm given the laxity of the patients anterior abd wall. We deployed a SurgiMend biologic prosthetic which is fetal bovine dermins in an underlay manner ultiizing a series of interrupted #1 prolene sutures in a horizontal mattress orientation. The mesh lay quite nicely at the conclusion of the repair under no tension with no wrinkling. Consequently there was sufficient laxity in the anteror abd wall musculature to allow us to then close the fascial border along the midline with series of fracture or dislocation #1 Prolen sutures. This was done no to buttress the repair but to place soft tissue separation between the underlying biologic prosthetic and the subcutaneous wound. Once this was completed, two 19 French Blake drains were placed in the subcutanous space, brought out through stab wounds in the right and left lower quadrants, stablized to the level of skin with 2-0 nylon sutures, and thenthe subcutanous tissues was further reapproximated with interrupted 3-0 polysorb sutures before deploying a delayed primary closure dessing which consisited of Xerform in the subcutaneous space, approx 10 vertical mattress 3-0 nylon sutures that were placed but not tied, and then a sertile gauze dressing placed over the midline incision. Prior to deploying the delayed primary closure, excess skin was excised from the midline wound along with excision of much of the old scar and association inflammation from the chronic fistulous tractss. Patient tolerated procdure quite well.
This was coded as:
44120
49402-51
49565-59
13101-59
15330-51
49568
13102 x4
15331 x2
Is that correct? I didn't see that any hernia repairs were performed and don't know if we can code the layered closures separatley? Can anyone please help?
Thanks
Simone Shofner CPC