Wiki right hemicolectomy CPT coding

[SallieF]

surgeon closed colostomy site at skin level, this colostomy had a large peristomal hernia which was repaired at the same time the surgeon also performed a right hemicolectomy leaving the terminal ileum to use for ileostomy. There is no anastamosis mentioned in the op note.
this surgeon has me running in circles because they want to charge for the colostomy revision, peristomal hernia repair, hemicolectomy and ileostomy. i am needing to code all of this surgery correctly.
if 44144 did not have the creation of mucofistula it would look like a candidate for this surgery.
any and all help is appreciated.
thank you

 

[colorectal surgeon]

You're going to have to post the op note on this one. This is always a confusing situation because there's not really a good code. Need to know more about the hernia.

I would code the colectomy 44150 since the remaining colon is removed and an ileostomy is created.

 

[SallieF]

op note

PROCEDURES PERFORMED
1. The patient underwent a right hemicolectomy.
2. End ileostomy.
3. Repair of peristomal hernia with Strattice mesh.

SURGEON

ASSISTANT
M.D. peristomal hernia and prolapse of the right colon colostomy.

SPECIMENS
Right colon..

INDICATIONS
This is an 80-year-old man has had a prolapse and peristomal hernia of his
right end colostomy.

DESCRIPTION OF PROCEDURE
After informed consent, the patient understands the risks, benefits, and
alternatives, he and his wife, and wished to proceed with surgery. The patient
was brought into the operating room. SCDs in place. Antibiotics have been
infused. After general anesthesia was achieved, the patient was prepped and
draped in sterile fashion. I used 2-0 silk stitch to close the colostomy at the
skin level. I made an incision at the mucocutaneous junction of the colostomy
and I carried this down circumferentially. There is a large hernia sac that was
incised and good 8 inches of the right colon prolapsed easily. Because he did
not have much more it would be a very poor function colostomy. I went ahead
made the incision larger in order to do a formal right hemicolectomy. We had to
make the incision larger at the fascia level medially and laterally in order to
get some adhesions down in his pelvis and get the appendix. The appendix was
retrocecal and stuck in the right gutter. I did all of this with sharp
dissection and using the Enseal device. Once we got the appendix and right
colon completely up I took down Jackson sail right there at the very distal
terminal ileum. I used a GIA 55 stapler blue load to staple across the terminal
ileum and make this our end ileostomy. Once this done, I started to take the
mesenteric vessels. I took the mesentery using the Enseal device and the
vessels using 0 ties. I sent colon off as a specimen, the right colon, and
appendix. I then irrigated to make sure there is good hemostasis. I then
brought up for the terminal ileum to make our ileostomy. I used Strattice mesh
in order to buffer the fascia. I sewed that end with 0 Prolenes using at least
a 2 cm underlay technique. Then once that was done circumferentially I made
sure the ileum was coming up under no tension. I then closed the fascia using 0
PDS interrupted sutures to close the fascia around the ileostomy. I did make a
keyhole incision for the ileum to come through the mesh. We then closed the
|skin with 2-0 Ethilon and the ileostomy with 2-0 Vicryl. All instrument and lap
counts were correct. The patient was stable throughout the entire case and was
taken to recovery.

 

[SallieF]

i have sent the op note do you have a moment to review it?

 

[colorectal surgeon]

So I don't think you can code for both. All work was done thru one incision. You could code the parastomal hernia (49561) and use of mesh (49568). Or you could code the colectomy. There's not a good code for this type of colon resection. Surgeon did a right hemicolectomy and end ileostomy. No true code for that. 44143 is the closest. This describes closure of the distal stump. The operative note doesn't state whether there was a distal stump or if it has been removed in the past. And while close, this doesn't truly fit.

I would code the hernia and mesh. It's the most correct way to do this.

Hope that helped.

 

[Lujanwj]

I'd get clarification from the DR. I would see if the rectum or anus was closed off at the time of the first colostomy leaving no colon on the left. If so, I'd look at 44150 because Dr would be removing the rest of the colon or doing a total with ileostomy. Remember, CPT doesn't address if there was a previous resection so you just need to make sure that the remaining colon is completely taken at this session. If there is still colon left, you'd code 44144-52. Dr did a resection and ileostomy but no mucofistula so I would add -52.

Hernia repair would not be appropriate as there was a resection done which is the more extensive procedure.

Just my 2 cents