Hello Everyone,
I'm a little stumped with this one. The general surgeon was assisting prior to a hysterectomy. He performed a Lap Appendectomy, then started to perform lysis of dense adhesions, but due to the extent of the adhesions he had to convert to an open procedure. I know that lysis of adhesions is usually not separately reportable expect by adding a 22 modifier. Is that the same in this case, the general surgeon did the primary surgery (appendectomy) laparoscopic and then had to convert to open for the lysis of adhesions? He is trying to bill a 44970 and a 44005.
Thank you for your help.
PREOPERATIVE DIAGNOSES:
1. Excessive uterine bleeding.
2. Complex right ovarian cyst.
3. Radiologic abnormality of the appendix.
*
POSTOPERATIVE DIAGNOSES:
1. Excessive uterine bleeding.
2. Complex right ovarian cyst.
3. Radiologic abnormality of the appendix.
*
OPERATIVE PROCEDURES PERTINENT TO MY INVOLVEMENT IN THE SURGERY:
1. Laparoscopic appendectomy.
2. Enterolysis of adhesions with imbrication of superficial serosal tear of the sigmoid colon.
3. Rigid proctosigmoidoscopy.
*
SURGEON:
Dr. General
*
CO-SURGEON:
Dr. Gynecology
*
ANESTHESIA:
General endotracheal anesthesia.
*
ESTIMATED BLOOD LOSS:
Per anesthesia record.
*
SPECIMENS PERTAINING TO MY INVOLVEMENT IN THE SURGERY:
Appendix.
*
COMPLICATIONS:
None apparent.
*
CONDITION:
Stable.
*
INDICATION FOR PROCEDURE:
The patient is a 44-year-old female whom I was kindly consulted to provide intraoperative consultation regarding the possible need for appendectomy. The patient had been seeing Dr. Gynecology for complaints of excessive uterine bleeding. Work-up included an ultrasound as well as a CT scan. Her ultrasound did reveal a complex right ovarian cyst. A CT scan, which was obtained by the primary care provider revealed an abnormal appendiceal tip that was approximately 8 mm in diameter. Based on this finding, I was asked by Dr. Gynecology to possibly assist during the surgery in the event that appendectomy would be indicated. Consent was obtained by Dr. Gynecology for this surgery, including my possible involvement.
*
DESCRIPTION OF PROCEDURE:
After Dr. Gynecology had placed a 5-mm umbilical port as well as another 5-mm right lower quadrant port and a 12-mm left lower quadrant port, I was called to the operating room as the appendix was found to be abnormal in appearance consistent with the CT findings. The tip of the appendix did seem to be enlarged compared to the rest of the appendix. There was no obvious evidence of appendicitis. At this time, I added a 5-mm port in the suprapubic region. Local anesthetic was injected at my intended port site. A 5-mm incision was made using a #15 blade scalpel. The 5-mm port was then inserted under direct visualization of the laparoscope. I grasped the appendix with an atraumatic grasper and dissected a window between the base of the appendix and the mesoappendix. The mesoappendix was taken down using a Harmonic scalpel. The appendix was then divided at its base at the cecum using a 45-mm Echelon endoscopic linear cutting stapler. This was done using a single blue bowel staple load. The appendix was then placed into an Endocatch bag and removed. It was saved for pathology.
*
As we turned our attention towards the pelvis, it was noted that the posterior uterine wall as well as the right ovary seemed to be tethered to the distal sigmoid colon at the approximate level of the rectosigmoid junction. I did make several attempts to free this up laparoscopically; however, given how dense this adhesive process seemed to be, I did not want to risk injuring bowel. Thus, both Dr. Gynecology and I decided it would be safest to convert to an open procedure.
*
At this time, I let Dr. Gynecology and her resident staff proceed with making the Pfannenstiel incision. Once we had adequate exposure, it was quite evident that there was an extensive adhesive process (which we attributed to endometriosis) between the posterior uterine wall, right ovary, and the colon wall. The right ovarian cyst was inadvertently ruptured during dissection. This seemed consistent with a chocolate cyst associated with endometriosis.
As we tried to separate everything, there was a small area of serosal tearing on the anterolateral aspect that I believe was unavoidable given how dense this adhesive tissue was despite our meticulous dissection. I then let her proceed with performing the right salpingo-oopherectomy, hysterectomy, and left salpingectomy. I was able to examine the anterior surface of the colon in much greater detail once the other structures had been removed. Again, there was only a small serosal tear without any evidence of full thickness mucosal injury. I imbricated the serosal tear using interrupted Lembert sutures of 3-0 silk. As an extra measure, I did perform an air leak test via a rigid proctosigmoidoscope. There was no evidence of any air bubbling within the saline that had been placed into the pelvis. At this time, my involvement in the case was complete.
I'm a little stumped with this one. The general surgeon was assisting prior to a hysterectomy. He performed a Lap Appendectomy, then started to perform lysis of dense adhesions, but due to the extent of the adhesions he had to convert to an open procedure. I know that lysis of adhesions is usually not separately reportable expect by adding a 22 modifier. Is that the same in this case, the general surgeon did the primary surgery (appendectomy) laparoscopic and then had to convert to open for the lysis of adhesions? He is trying to bill a 44970 and a 44005.
Thank you for your help.
PREOPERATIVE DIAGNOSES:
1. Excessive uterine bleeding.
2. Complex right ovarian cyst.
3. Radiologic abnormality of the appendix.
*
POSTOPERATIVE DIAGNOSES:
1. Excessive uterine bleeding.
2. Complex right ovarian cyst.
3. Radiologic abnormality of the appendix.
*
OPERATIVE PROCEDURES PERTINENT TO MY INVOLVEMENT IN THE SURGERY:
1. Laparoscopic appendectomy.
2. Enterolysis of adhesions with imbrication of superficial serosal tear of the sigmoid colon.
3. Rigid proctosigmoidoscopy.
*
SURGEON:
Dr. General
*
CO-SURGEON:
Dr. Gynecology
*
ANESTHESIA:
General endotracheal anesthesia.
*
ESTIMATED BLOOD LOSS:
Per anesthesia record.
*
SPECIMENS PERTAINING TO MY INVOLVEMENT IN THE SURGERY:
Appendix.
*
COMPLICATIONS:
None apparent.
*
CONDITION:
Stable.
*
INDICATION FOR PROCEDURE:
The patient is a 44-year-old female whom I was kindly consulted to provide intraoperative consultation regarding the possible need for appendectomy. The patient had been seeing Dr. Gynecology for complaints of excessive uterine bleeding. Work-up included an ultrasound as well as a CT scan. Her ultrasound did reveal a complex right ovarian cyst. A CT scan, which was obtained by the primary care provider revealed an abnormal appendiceal tip that was approximately 8 mm in diameter. Based on this finding, I was asked by Dr. Gynecology to possibly assist during the surgery in the event that appendectomy would be indicated. Consent was obtained by Dr. Gynecology for this surgery, including my possible involvement.
*
DESCRIPTION OF PROCEDURE:
After Dr. Gynecology had placed a 5-mm umbilical port as well as another 5-mm right lower quadrant port and a 12-mm left lower quadrant port, I was called to the operating room as the appendix was found to be abnormal in appearance consistent with the CT findings. The tip of the appendix did seem to be enlarged compared to the rest of the appendix. There was no obvious evidence of appendicitis. At this time, I added a 5-mm port in the suprapubic region. Local anesthetic was injected at my intended port site. A 5-mm incision was made using a #15 blade scalpel. The 5-mm port was then inserted under direct visualization of the laparoscope. I grasped the appendix with an atraumatic grasper and dissected a window between the base of the appendix and the mesoappendix. The mesoappendix was taken down using a Harmonic scalpel. The appendix was then divided at its base at the cecum using a 45-mm Echelon endoscopic linear cutting stapler. This was done using a single blue bowel staple load. The appendix was then placed into an Endocatch bag and removed. It was saved for pathology.
*
As we turned our attention towards the pelvis, it was noted that the posterior uterine wall as well as the right ovary seemed to be tethered to the distal sigmoid colon at the approximate level of the rectosigmoid junction. I did make several attempts to free this up laparoscopically; however, given how dense this adhesive process seemed to be, I did not want to risk injuring bowel. Thus, both Dr. Gynecology and I decided it would be safest to convert to an open procedure.
*
At this time, I let Dr. Gynecology and her resident staff proceed with making the Pfannenstiel incision. Once we had adequate exposure, it was quite evident that there was an extensive adhesive process (which we attributed to endometriosis) between the posterior uterine wall, right ovary, and the colon wall. The right ovarian cyst was inadvertently ruptured during dissection. This seemed consistent with a chocolate cyst associated with endometriosis.
As we tried to separate everything, there was a small area of serosal tearing on the anterolateral aspect that I believe was unavoidable given how dense this adhesive tissue was despite our meticulous dissection. I then let her proceed with performing the right salpingo-oopherectomy, hysterectomy, and left salpingectomy. I was able to examine the anterior surface of the colon in much greater detail once the other structures had been removed. Again, there was only a small serosal tear without any evidence of full thickness mucosal injury. I imbricated the serosal tear using interrupted Lembert sutures of 3-0 silk. As an extra measure, I did perform an air leak test via a rigid proctosigmoidoscope. There was no evidence of any air bubbling within the saline that had been placed into the pelvis. At this time, my involvement in the case was complete.