Wiki Very difficlut multi procedure coding question

Coastal Coder

Salem, VA
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Good Morning everyone,

I would appreciate any help with this that I can get. Lap Chole was preformed(very extensive 1.5 hr procedure), He tried to do a Lap Right hemicolectomy that was converted to open, then went back to the liver bed again. I know that the lap to open can only be coded as open, but what if anything can I do about charging for the lap chole? Thanks for any help with this. Note is below.


was brought back to the operating room, placed in supine position. Perioperative antibiotics were administered in accordance with SCIP protocol. General anesthesia was induced. The patient was intubated without complication. Foley was placed. The abdomen was shaved, prepped, and draped in a normal sterile fashion. A supraumbilical 12 mm Hasson port was placed using Hasson technique under direct visualization. The abdomen was insufflated without any hemodynamic changes. The patient was positioned. Three 5 mm ports were placed in the epigastrium and right upper quadrant under direct visualization. The gallbladder was grasped and elevated over liver. The omentum and colon were adherent to the gallbladder. These were taken down sharply.
The infundibulum was grasped and retracted laterally. Dissection was very tedious as he had evidence of both acute and chronic cholecystitis and completely filled the gallbladder. There is extensive fibrotic change all around the gallbladder. After an hour and a half of patient dissection we obtained the critical view. The cystic duct was clipped with two clips down and one clip up and transected with laparoscopic scissors. The cystic artery was clipped and cut in a similar fashion.
The gallbladder was then removed from the liver bed using electrocautery. This was also incredibly tedious given the extent of scarring as well as a markedly intrahepatic gallbladder. In addition, he had a nodular and very cirrhotic liver and this was causing him to be somewhat coagulopathic. The liver bed was inspected for hemostasis. It was noted that we had gotten into one of the branches of the hepatic veins. This was controlled using clips and electrocautery. We placed some Surgicel on the liver bed. The entire area was irrigated out copiously as there had been some spillage of bile and stones. These were irrigated out to the best of our ability.

Attention was then turned to the second part of the procedure. We placed two additional ports one 5 port in the suprapubic position and a 12 port in the left mid abdomen both under direct visualization. We began by dissecting out the ileocolic vessels. We came across the iliac vein with a Ligasure. This resulted in significant bleeding which was controlled using a grasper. We then decided to do our dissection from lateral to medial fashion to then better expose this area for definitive management. We began dissecting up the White line of Toldt to medialize the colon. Unfortunately, the lateral plan was not clear, the decision was made to convert to an open colectomy.
We made a small lower midline incision and completed our lateral dissection mobilizing the right colon up to the hepatic flexure in and around onto the transverse colon. Attention was then turned back to the terminal ileum. A window was made through the mesentery and the terminal ileum was transected with an 80 mm blue load GIA stapler. The mesentery was clamped and cut and tied off with 0 Vicryl sutures. This was mobilized up to the hepatic flexure. We then mobilized the omentum off the colon through the avascular plane. We identified the area of tattooing which was just distal to the mid transverse colon. We continued to clamp and cut the mesentery until we reached passed our tattooed mark. We created a window through the mesentery and transected the colon using a blue load 80 mm stapler. The specimen was passed off the field. It was opened on the back table and revealed the area of interest which included a followup.
We then irrigated the abdomen and inspected again for hemostasis which was apparent. At this point, we decided to readdress our liver bed to insure that this was hemostatic. We irrigated the right upper quadrant and removed all of the remaining gallstones that had spilled. Hemostasis was apparent. Because he did appear to have some degree of coagulopathic bleeding, we placed Surgicel over the liver bed and cauterized this once more. Attention was then turned to creating our side-to-side functional end-to-end ileocolonic anastomosis. The two ends of bowel were aligned and two stay sutures were placed to maintain our alignment. The corners of the staple lines were transected and each of the ends of bowel were entered. The anastomosis was created using an 80 mm blue load GIA stapler. There was no bleeding apparent on the staple line. The common channel was closed using a TA stapler. The mesenteric defect was closed using 3-0 interrupted figure-of-eight Vicryl sutures. The abdomen was irrigated once more. The anastomosis appeared to be widely patent. We then closed the fascia using a running #1 PDS and the skin was closed with staples. The laparoscopic port sites were closed with 4-0 Vicryl subcuticular sutures.
The area of the prior cholecystostomy tube had a hypergranulated fistula tract. We excised this using a combination of electrocautery and sharp dissection and fulgurated the tract. The wound was then closed with two 2-0 vertical mattress nylon sutures. All sponge, needle, and instrument counts were reported as correct at the conclusion of the procedure.