bonnienorth55
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My brain has been spinning in circles trying to figure out what is bundled & what's not 
Op report info listed below:
Indication for surgery: Pt w/large incisional hernia with multiple episodes of small bowel obstruction.
Findings:
1. Enterocutaneous fistula secondary to previous mesh
2. Compromised small bowel
3. Multiple incisional hernias with a total length of 15 cm
4. Extensive intra-abdominal adhesions
Report lists technical procedures as:
EXPLORITORY LAPAROTOMY, REMOVAL OF ENTEROCUTANEOUS FISTULA, SMALL BOWEL RESECTION, REMOVAL PRIOR MESH, REPAIR RECURRENT INCISIONAL HERNIA WITH MESH
Procedure Description:
The patient was brought to the OR, proper identification and procedure were confirmed with the initial timeout. Patient was then prepped and draped in the usual sterile fashion. Final timeout protocol was then followed and the surgery was started. Midline incision was made carried into the subcutaneous tissue was encountered a large ventral hernia. Carefully dissected into the abdominal cavity. Then spent about an hour and a half taking down adhesions. Ultimately identifying a chronic subcutaneous sinus tract to the skin from previous mesh and suture. This area of the bowel was very thin and upon taking it down created a big enterotomy. The enterotomy was briefly closed to minimize the spilling. And then we continued to take down the remaining of the adhesions. There was also another area of small bowel that was attached to a smaller subcutaneous chronic sinus tract which was adjacent to the previous area and thus in the evaluation elected to resect both areas. The mesentery between the proximal and distal bowel was divided between clamps. The proximal and distal areas from the resection were laid side-to-side and a posterior row 3 oh silks were placed and enterotomy was made in each end of the planned anastomosis and then the GIA stapler was placed and fired and then the enterotomy was closed with another firing of the GIA stapler. The mesentery was closed with 2-0 Vicryl. We then inspected the small bowel for any concerns requiring repair and serosal tears or enterotomies that were none. The fascial layer on each side was then identified and wide flaps were created to allow mobilization of the fascia for subsequent repair. It was clear that there would be significant tension and thus a biologic mesh was chosen to enhance closure. While taking down the hernia sac, some of the mesh that was removed as well. The abdomen was then irrigated with copious amounts normal saline hemostasis was assured and then we proceeded placing the mesh. Biologic mesh was approximately 15 cm in length. The mesh was secured to the fascial edge with approximately 3 to 5 cm of overlap approximately it was secured to the mesh with interrupted 2-0 PDS circumferentially. Once having the mesh completely placed the fascia was reapproximated with running #1 PDS. The fascia did come together in the midline. Subcutaneous tissue was irrigated with normal saline inspection for any residual hernia sac was done there was none 2 wound 15 French Blake drains were placed in the subcutaneous tissue bilaterally the subcutaneous tissue was closed with a running 2-0 Vicryl and the skin was closed with surgical staples. Drains were secured into position with 3-0 nylon
I have fistula closure = 44640, hernia repair = 49617 w/49623 for removal of the old mesh, small bowel resection = 44120. From what I've been reading while researching, the hernia repair would not be separately billable with the other abdominal procedures since all through the same incision site. But the hernia was the primary reason for the procedure so I'm not sure if that changes anything...then I thought we could bill 44640 and 44120 but a CCI edit pops up with those codes as well. Having a hard time figuring out what can be billed in this scenario. Any advice is greatly appreciated, thank you!
Op report info listed below:Indication for surgery: Pt w/large incisional hernia with multiple episodes of small bowel obstruction.
Findings:
1. Enterocutaneous fistula secondary to previous mesh
2. Compromised small bowel
3. Multiple incisional hernias with a total length of 15 cm
4. Extensive intra-abdominal adhesions
Report lists technical procedures as:
EXPLORITORY LAPAROTOMY, REMOVAL OF ENTEROCUTANEOUS FISTULA, SMALL BOWEL RESECTION, REMOVAL PRIOR MESH, REPAIR RECURRENT INCISIONAL HERNIA WITH MESH
Procedure Description:
The patient was brought to the OR, proper identification and procedure were confirmed with the initial timeout. Patient was then prepped and draped in the usual sterile fashion. Final timeout protocol was then followed and the surgery was started. Midline incision was made carried into the subcutaneous tissue was encountered a large ventral hernia. Carefully dissected into the abdominal cavity. Then spent about an hour and a half taking down adhesions. Ultimately identifying a chronic subcutaneous sinus tract to the skin from previous mesh and suture. This area of the bowel was very thin and upon taking it down created a big enterotomy. The enterotomy was briefly closed to minimize the spilling. And then we continued to take down the remaining of the adhesions. There was also another area of small bowel that was attached to a smaller subcutaneous chronic sinus tract which was adjacent to the previous area and thus in the evaluation elected to resect both areas. The mesentery between the proximal and distal bowel was divided between clamps. The proximal and distal areas from the resection were laid side-to-side and a posterior row 3 oh silks were placed and enterotomy was made in each end of the planned anastomosis and then the GIA stapler was placed and fired and then the enterotomy was closed with another firing of the GIA stapler. The mesentery was closed with 2-0 Vicryl. We then inspected the small bowel for any concerns requiring repair and serosal tears or enterotomies that were none. The fascial layer on each side was then identified and wide flaps were created to allow mobilization of the fascia for subsequent repair. It was clear that there would be significant tension and thus a biologic mesh was chosen to enhance closure. While taking down the hernia sac, some of the mesh that was removed as well. The abdomen was then irrigated with copious amounts normal saline hemostasis was assured and then we proceeded placing the mesh. Biologic mesh was approximately 15 cm in length. The mesh was secured to the fascial edge with approximately 3 to 5 cm of overlap approximately it was secured to the mesh with interrupted 2-0 PDS circumferentially. Once having the mesh completely placed the fascia was reapproximated with running #1 PDS. The fascia did come together in the midline. Subcutaneous tissue was irrigated with normal saline inspection for any residual hernia sac was done there was none 2 wound 15 French Blake drains were placed in the subcutaneous tissue bilaterally the subcutaneous tissue was closed with a running 2-0 Vicryl and the skin was closed with surgical staples. Drains were secured into position with 3-0 nylon
I have fistula closure = 44640, hernia repair = 49617 w/49623 for removal of the old mesh, small bowel resection = 44120. From what I've been reading while researching, the hernia repair would not be separately billable with the other abdominal procedures since all through the same incision site. But the hernia was the primary reason for the procedure so I'm not sure if that changes anything...then I thought we could bill 44640 and 44120 but a CCI edit pops up with those codes as well. Having a hard time figuring out what can be billed in this scenario. Any advice is greatly appreciated, thank you!