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Post-op visit after total colectomy

maine4me

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Patient had a total colectomy with transection of the recto-sigmoid junction, creation of Brook ileostomy and extensive lysis of adhesions. During the post-op period the patient returned for follow-up the discussion of patient's inability to care for his ileostomy and his which a reversal. After a lengthy discussion it was agreed that the surgoen would perform an the reversal, and that due to the patient's post-op complications from gallstones a laparoscopic cholecystectomy would also be performed. My gut feeling is this is simply a post-op visit. The doctor wishes to bill and E/M code. If coding an E/M what modifiers should be used? 24 seems inappropriate because the reason for visit is directly related to the original surgery. Any feedback would be appreciated.
 
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Cholecystectomy may NOT be related

Without seeing all the documentation it's hard to tell, but it's possible that the need for the total cholecystectomy would be considered UNrelated to the colectomy. If that IS the case, you will choose a level of service based on the documentation related to THIS condition only.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

maine4me

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See the visit note below. Maybe this will help clarify my dilemma.

STATUS REPORT: Patient underwent total colectomy with transection of the recto-sigmoid junction, creation of Brooke ileostomy and extensive lysis of adhesions on 2/20/11. Post operative course was complicated by pulmonary embolus and patient is currently taking Coumadin. When last seen in the office, I recommended against reversal of his ileostomy, even though the ileostomy is problematic for this patient who has marked reduction in visual capabilites. At our last discussion, patient was informed that I would not proceed with ileostomy reversal until I discussed this with the patient and his son in person. The patient now presents with his son available for that discussion. The patient is unable to care for h is ileostomy. His wife is in a nursing home and the patient lives in a personal care apartment in the same nursing complex.

PHYSICAL EXAM: Not performed.

PLAN:
1. Long discussion with patient and the patient's son, as well as patient's daughter by phone from Indiana regardign the ileostomy reversal. I have explained to all of them that I think it is an unnecessary risk to this elderly patient and may result in his death. The patient is adamant that he does not want to be dependant on others and since he cannot see, wll, he cannot care for the ileostomy himself. I have gone over, again, all of the risks/benefits of surgical vs. non surgical approches regarding care for his ileostomy. The patient remains adamant that he wants to proceed with ileostomy reversal, with ileoproctostomy. The problems with an ileoproctostomy at this patient's age were also reviewed in detail. (Forty minutes of discussion was held with this patien tand the patient's family at this visit).
2. Have agreed to proceed with ileostomy reversal and creation of ileoproctostomy, after cardiac evaluation.
3. Patient will require IVC filter at least on a temporary basis.
4. Will scheule, once seen by cardiology.
5. Since patient has know gallstones which were problematic in his recent postoperative coure, will also proceed with laparoscopic cholecystectomy, possible open cholecystectomy. If possilbe, the ileostomy reversal will also be done using hand-assisted laparoscopic techniques.

As you can see the gall stones and cholecystectomy seem to be a last minute add on. Advice please.
 
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