Wiki Laparatomy,biopsies, resection/anastomosis

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hsmith67

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All right, here's another I would appreciate help on.

Procedures: Exploratory laparotomy, small bowel resection with side to side anastomosis, and excisional biopsies of small bowel mesenteric nodules X2.

I get that exploratory laparatomy includes biopsy/ies. I get that exploratory laparatomy is a "separate procedure" and should not be billed when "other" procedure done as a result of laparatomy. But, the resection is in my mind a "major" procedure and the laparatomy with 2 biopsies is a "major" procedure. So...do I bill the laparatomy, the resection, or both with a 51? I just have a hard time with a "major" procedure being done for free. Am I wrong?

Please help!

Thanks,
Hunter Smith, CPC
 
please post op note

Considered codes are
44120
49203

Exploratory laparotomy is a separate procedure and cannot be billed with an open procedure and plus, 44120 has a higher RVU. That will for sure CCI edit.

MS
 
Thanks for the help!

Thanks so much for taking the time out to help in any way you can.

After all the typical starting info, below is the op note after entering abdomen:

The small bowel was eviscerated. It was noted that in the right lower quadrant, the small bowel was adherent to the peritoneum and was stuck in the small bowel and partially towards the right upper quadrant. This was mobilized along with the cecum and right colon along the lines of Toldt. Once the adhesions were lysed and the bowel mobilized the bowel was then run from the ligament of Treitz to the terminal ileum. In the mid jejunal portion, there was an area that was palpated on the small bowel that was mass-like in nature. A decision was made at this point to resect the small piece of bowel measuring approximately 1-1/2 to 2 inches. The resection was carried out using a GIA 75 stapling device. A small hole was made in the mesentery both proximally and distally to the area of concern and the bowel was resected with a GIA 75 stapling device. The specimen was then clamped with a Kelly clamp and the specimen was amputated and passed off the table. It was then opened and there was an ulceration measuring approximately 2 cm in the luminal wall of the bowel. A silk suture was placed and it was sent for frozen section and pathology by Dr.... The mesentery was tied with 2-0 silk sutures and the bowel was then placed in a side-to-side fasion and reanastomosed with a 75 GIA stapling device and the end was closed with a TA60 stapling device. The suture line was oversewn with 3-0 silk sutures for hemostasis. There was no other lesion palpated in the rest of the small bowel all the way to the terminal ileum. The cecum was without any masses as well as the ascending, transverse, left colon, sigmoid colon, and rectum. The liver was also free of any surface lesions that were palpated. The NG tube was noted to be in good position in the greate curvature of the stomach secured at the nares. The abdominal cavity was then irrigated with copious amount of bacitracin and saline solution in each quadrant.

So, just bill a 49000?

Hunter Smith, CPC
 
You have to look at the history and why they came for exploratory laparotomy in the first place. Was there a concern for malignant masses, history of malignancy? If the reason was in concern of a mass, I think it warrants to reporting the 49203 per size and if you read the instructions on top of page 254, it says to code for bowel resection.

You can wait for path to help with decision on nature of the mass and if it originated from the small bowl, it may just be fat necrosis...you can be safe just reporting 44120. Do not report the exploratory laparotomy code alone, you have two better options that are more correct.

So its either

44120
Or
49203, 44120

MS
 
From the note, the only mass/tumor was the one that was included in the portion of the small bowel that was removed. The only code you can use would be the 44120. The code 49203 reads, "Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas..." This surgery does not qualify as your tumor was within the GI tract and was not intra-abdominal.

The surgeon did one procedure, an excision of part of the small bowel with an anastomosis of the two ends remaining. The tumor was within the bowel and sent to pathology so the surgeon did not actually do anything to the tumor directly. Therefore, one code....

Hope that makes sense!

V Davis CPC CGIC
 
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