Question How to code this one

cbutsko

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Good morning,

I'm not quite sure what cpt codes I should use for this case. Op report states:

Postoperative Diagnosis:

1. Symptomatic alkaline gastric reflux
2. Marginal ulcer at gastrojejunostomy anastomosis
3. History of Billroth II

The procedure began by first excising the previous upper abdominal laparotomy scar that was present from xiphoid to the umbilicus. Once the previous cicatrix was excised dissection was carried down through the subcutaneous tissues to the level of the fascia with Bovie cautery. While approaching the fascia there were many wire sutures from her previous surgery that were encountered which were dissected and removed. The linea alba was identified and incised. Preperitoneal fat was dissected from the peritoneum and subsequent access was gained into the peritoneal cavity. The abdomen was explored and omental adhesions to the anterior abdominal wall were lysed sharply under direct vision with Metzenbaum scissors. A self-retaining Balfour retractor was then placed. Further lysis of adhesions were performed within the vicinity of the previous Billroth II gastrojejunostomy anastomosis.

The previous Billroth II gastrojejunostomy anastomosis was identified and the small bowel from this anastomosis was ran in its entirety to the ligament of Treitz and to the terminal ileum correctly identifying the afferent and efferent limbs. The proximal afferent limb was identified and a small mesenteric window was made and a blue load Endo GIA stapler was used to transect the jejunum adjacent to the anastomosis. The staple line was reinforced with interrupted 3-0 silk Lembert sutures. This proximal jejunal stump was then brought down distally to approximately 40 cm along the Roux limb and a side-to-side stapled jejunojejunostomy was created in the usual fashion with a blue load GIA stapler. The staple line was again reinforced with interrupted 3-0 silk to prevent an internal hernia. The lumen of the anastomosis was palpated and noted to be widely patent. We ensured that the small bowel laid comfortably within the abdomen then doing so noted that there was an omental adhesion that required to by lysed and this was completed by applying 2 Carmalt's distally on the omentum and transecting the omentum with Bovie cautery between the clamps and tying them off with 0 Vicryl sutures. All of the small bowel and transverse colon and omentum were inspected and there were no areas that appeared to be under tension.

Hemostasis was checked. There was noted a superficial tear in the diaphragm that was repaired with 2 figure-of-eight 0 Vicryl sutures. The peritoneum was closed.....etc, etc.

END OF OP NOTE

I'm pretty sure I'm going to have to use an unlisted code for this one, but I need to know what to compare it to in order to bill the procedure. When the surgeon turned in the charges he listed Exploratory Laparotomy (which I know is bundled), Conversion of a Billroth II to a Roux-en-y, Jejunojejunostomy, Lysis of Adhesions 30 minutes (which I know is bundled), and Excision of abdominal wall cicatrix (which I know is bundled.)

Your thoughts/input would be most appreciated!

Thank you,

Cate
 
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