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Need coding advice hernia/mesh rem etc.

  1. Default Need coding advice hernia/mesh rem etc.
    Medical Coding Books
    Hi all- Was wondering if anyone had any thought on how to bill this. Our doctor wants to bill:
    First 3 codes all bundle together, wondering if anyone has any other ideas on codes? Would be much appreciated!

    PREOPERATIVE DIAGNOSIS: Small bowel obstruction secondary to recurrent
    incisional hernia and adhesions.

    POSTOPERATIVE DIAGNOSIS: Small bowel obstruction secondary to recurrent
    incisional hernia and adhesions, infected mesh, chronic infection of abdominal

    OPERATION PERFORMED: 1. Diagnostic laparoscopy.
    2. Exploratory laparotomy with extensive lysis of adhesions.
    3. Excision of infected mesh.
    4. Open repair of recurrent incarcerated incisional hernia.
    5. Debridement of abdominal wall

    INDICATIONS FOR SURGERY: This is an 80-year-old female who has undergone four
    previous exploratory laparotomies, two for colonic resection for acute
    gastrointestinal bleeding, and the other two for repair of an incisional
    hernia, followed by repair of a recurrent incisional hernia that later became
    infected for which the patient is on chronic antibiotics. The patient for the
    last two weeks had a decreased appetite, changes in her bowel habits, and for
    the last 48 hours had acute onset abdominal pain with intolerance to food, and
    a poor appetite. CT scan was concerning for a thickening of a segment of small
    intestine for potential bowel ischemia. There was also dilated bowel loops
    within the hernia defect, and collapsed small intestine distal to the hernia.
    It was decided to proceed, therefore, with a diagnostic laparoscopy with a
    possible conversion to an exploratory laparotomy to evaluate the intestine and
    resolve the obstruction. Following discussion of the risks and the benefits,
    the patient was consented for the following procedure.

    OPERATIVE REPORT: Patient was brought into the operating room and placed in
    the supine position with both arms tucked. The patient's abdomen was prepped
    and draped. Patient had received prophylactic antibiotics and a Foley catheter
    had been placed. A right upper quadrant incision was made and a cutdown
    technique was performed. The external oblique aponeurosis was visualized and
    incised. These were grasped with Kochers. A S retractor was then placed, and
    the same was repeated for the internal oblique layer, followed by the
    transversus abdominis layer. The peritoneal layer was visualized, this was
    incised with an 11 blade, and the empty 5 mm port was inserted without any
    resistance. Pneumoperitoneum was initiated. A 30 degree 5 mm scope was
    introduced which demonstrated extensive adhesions. An additional 5 mm port was
    placed 5 cm inferior to this along the anterior axillary line. This allowed us
    to introduce an atraumatic bowel grasper, however, we decided that given the
    extent of the adhesions we would proceed with an exploratory laparotomy.
    Therefore, the pneumoperitoneum was evacuated and a midline incision would be
    done. This was quite tedious as the bowel loops were essentially stuck to the
    mesh that the patient had had placed previously.

    Using Kocher clamps on either side we mobilized the intestine off of the
    anterior abdominal wall in order to continue making our midline incision
    following the entire length of the patient's previous scar. Small intestine
    itself appeared viable, although there were segments that appeared more
    fluid-filled than others. We then proceeded with a very lengthy and extensive
    lysis of adhesions, avoiding any enterotomies. There was one serosal tear,
    however, that was repaired using interrupted 3-0 silk sutures. Eventually, we
    found two smaller separate hernia defects that had been mentioned on CT scan as
    being potential transition points and the bowel had been released from those
    defects. Eventually, once the lysis of adhesions was completed we were able to
    follow the bowel from the ileocolonic anastomosis up to the ligament of Treitz.
    The bowel appeared to be viable. The bowel did not appear to show any other
    evidence of injury. We therefore decided to proceed with closure. On careful
    inspection of the Proceed light weight Marlex mesh, we decided to excise part
    of it. Upon excising it we entered an area where there was an abscess. The
    entire part of that mesh was excised including the surrounding abdominal
    wall in order to incorporate the entire abscess itself. The specimen was sent
    to pathology. Specimen 1 was the abscess itself, specimen 2 was the remainder
    of the redundant mesh that we had excised. More laterally, there was mesh
    remaining that would be helpful in closure of the abdomen with hopefully
    definitive repair of her hernia.

    The midline incision was closed using a running #1 Prolene suture with
    intervals of closure of figure-of-eight with 0 Vicryls in order to decrease the
    chance of dehiscence. The subcutaneous tissues were closed with a running 3-0
    Vicryl suture, and the skin was closed with skin staples. The subcutaneous
    tissues had been irrigated with saline prior to final closure of the skin. A
    dry dressing was then placed.

    The estimated blood loss from the procedure was 100 cc.

    Sponge, instrument, and needle counts were correct at the end of the procedure.

    The patient was awakened from general anesthesia and taken to the recovery room
    in stable condition.

  2. #2
    only thing billable is open repair of recurrent hernia............all other codes bundle .

  3. #3
    cms policy manual

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