Hello All!
I need help with a CPT code. According to the Op Note, the doctor preformed: 1- Lysis of Adhesions; 2 - Splenic Flexure Takedown; 3 - Total Abdominal Colectomy; 4 - J-Pouch Ileorectal Anastomosis; 5 - Proctoscopy; 6 - Layered closure. The surgery was done laparoscopically. I have codes for everything but the J-pouch. All it says in the Op Note about the J-Pouch is:
A small J-Pouch was then made at the transected terminal ileum area. A small enterotomy was made at the bottom of the J and another 60 mm blue load stapler on the Echelon stapler was used to place in this area and a stapler was fired across the 2 walls of the small bowel. Brief evaluation showed complete hemostasis and a good J-Pouch. A pursestring suture was then placed at the common enterotomy, and a 28 mm EEA Anvil was placed, and the pursestring suture tied down. The Anvil along with the terminal ileum J-Pouch was placed back inside the abdomen.
I looked at code 45113, but when I asked the doctor he said that he didn't remove the rectum or its mucosa. Is there another code that I should look at or should I use 45113 and add a -52 modifier on it?
Thanks in advance!!
I need help with a CPT code. According to the Op Note, the doctor preformed: 1- Lysis of Adhesions; 2 - Splenic Flexure Takedown; 3 - Total Abdominal Colectomy; 4 - J-Pouch Ileorectal Anastomosis; 5 - Proctoscopy; 6 - Layered closure. The surgery was done laparoscopically. I have codes for everything but the J-pouch. All it says in the Op Note about the J-Pouch is:
A small J-Pouch was then made at the transected terminal ileum area. A small enterotomy was made at the bottom of the J and another 60 mm blue load stapler on the Echelon stapler was used to place in this area and a stapler was fired across the 2 walls of the small bowel. Brief evaluation showed complete hemostasis and a good J-Pouch. A pursestring suture was then placed at the common enterotomy, and a 28 mm EEA Anvil was placed, and the pursestring suture tied down. The Anvil along with the terminal ileum J-Pouch was placed back inside the abdomen.
I looked at code 45113, but when I asked the doctor he said that he didn't remove the rectum or its mucosa. Is there another code that I should look at or should I use 45113 and add a -52 modifier on it?
Thanks in advance!!