Laparoscopic resection of colon polyp

jdibble

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Any ideas on how to code this procedure?

Preoperative Diagnosis
Adenomatous polyp of right colon _

Postoperative Diagnosis
Same _

Procedure Performed
Laparoscopic resection of colon polyp

Indications
Recurrent adenomatous polyp that could not be resected endoscopically

The patient was taken the operating room and after the induction of satisfactory general endotracheal anesthesia was prepped and draped in usual sterile fashion the low lithotomy position. A Veress needle was inserted the umbilicus after local anesthesia and after a positive drip test 1st low then high flow pneumoperitoneum was used to distend the abdomen. A 5 millimeter trocar was placed in the left middle quadrant using optical technique. Exploratory laparoscopy was performed and the tattoo was visualized in the ascending colon just above the cecum. Additional 5 millimeter trocar was placed at the umbilicus in the epigastrium and using a combination of blunt dissection and the Harmonic scalpel, the right colon was mobilized away from its lateral attachments up over the hepatic flexure. This allowed this to be rotated medially identifying the duodenum. A 3 inch incision was created around the umbilicus and the cecum was eviscerated along the terminal ileum and appendix. The area of tattoo was posterior and a small the enterotomy was performed through the tinea of the cecum. Exploration of the colon revealed the area that appeared to be not just tattoo but harboring the flat polyp which was described as about 30 millimeters. This was circumferentially dissected using the Bovie cautery, taking care to preserve enough for closure around the ileocecal valve without obstruction. The appendix was also taken by dividing the mesentery with Harmonic scalpel and stapling the appendix parallel to the incision using a white loaded linear endo-stapler. The specimen was sent for pathology and this revealed no evidence of cancer. This was then closed in 2 layers with a continuous full-thickness 3 0 Vicryl suture as the 1st layer and a 2nd seromuscular layer of silk sutures in a Lembert type fashion. The colon was then reduced into the abdominal cavity . Further exploration revealed hemostasis was controlled and after irrigating and aspirating the remainder of the abdomen was examined with the above findings. The extraction incision was closed using several 0 Prolene sutures in a running fashion, and subcutaneous tissues closed with a 3 Vicryl suture. Skin was coapted using a subcuticular suture and Steri-Strips. Occlusive bandages were then placed. The patient tolerated the procedure satisfactorily returned to recovery in stable condition all final sponge and instrument needle counts correct.

My surgeon has done a similar procedure in the past (without the appendix removal) and we billed with the unlisted code 44238 with a comparison to code 44110. It was denied by Medicare for medical necessity (we are appealing it right now) we are assuming because they believe it should have been done by endoscopy . So, I am not sure if this is the correct way to code, or would 44202-52 be the correct way to code? Or is there another code?

I would appreciate some help with this! :D

Thanks,
 

blckjnpr

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I would agree with billing the unlisted code with comparison to 44110 if open since 44110 describes what was done except for approach. 44202-52 seems to be a bit of a stretch, but I suppose a case could be made for billing that way too.
 

jdibble

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I would agree with billing the unlisted code with comparison to 44110 if open since 44110 describes what was done except for approach. 44202-52 seems to be a bit of a stretch, but I suppose a case could be made for billing that way too.
Thanks for your answer. I think I will try this and hopefully it will not get denied for medical necessity as the last time I coded this scenario. :)
 
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