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Minimally Invasive Lap- help

  1. #1
    Default Minimally Invasive Lap- help
    Exam Training Packages
    I am pulling my hair out any guru's who can help. I put Cpt codes that i came up with.. They may all be bundled.. ANY HELP I would so appreciate it

    PROCEDURES:
    1. Minimally invasive esophagectomy. CPT 43289
    2. Right thoracoscopy with mobilization of esophagus. CPT??????
    3. Laparoscopy with mobilization of stomach and creation of gastric
    conduit. CPT?????
    4. Placement of feeding jejunostomy tube. CPT 44015
    5. Botox injection of pylorus. CPT ????
    6. Left neck exploration and creation of end-to-side esophagogastric
    anastomosis. ??????? cpt
    7. Bronchoscopy. ?????? cpt

    DESCRIPTION OF PROCEDURE:


    - PREOPERATIVE DIAGNOSIS:
    Cancer of the gastroesophageal junction status post induction
    chemoradiotherapy.
    POSTOPERATIVE DIAGNOSIS:
    Cancer of the gastroesophageal junction status post induction
    chemoradiotherapy.
    DESCRIPTION OF PROCEDURE:
    The patient was brought to the operating room and placed initially supine
    on a stretcher. A thoracic epidural was placed, followed by Foley
    catheter, A line, and IVs. The patient was intubated and a double-lumen
    endotracheal tube was placed. Its position was confirmed
    bronchoscopically. The patient was then positioned prone on the operating
    table with care taken to pad his head and arms appropriately. The arms
    were abducted at the shoulder at 90 degrees and the elbows again were at
    90 degrees. The table was jackknifed at 25 degrees at the hips and a bean
    bag was rolled underneath his right side to elevate his chest. After
    prepping and draping the right chest in the appropriate fashion,
    landmarks were identified with a marker and a 5 mm stab incision was made
    just at the tip of the scapula. Insufflation was performed by inserting a
    Veress needle. A 5 mm port was placed followed by the 5 mm camera. There
    were no adhesions of the lung to the chest wall. A 12 mm port was placed
    in the anterior axillary line at approximately the fifth intercostal
    space and another 5 mm port was placed in the posterior axillary line at
    approximately the seventh intercostal space. Starting out with a hook
    cautery, the pleura was incised overlying the esophagus. The azygous vein
    was dissected free and an Endo-GIA stapler was used to transect it. The
    esophagus was encircled with a 5/8 Penrose drain which was stapled off
    with a blue load of the stapler. This Penrose drain was used as a handle
    to help mobilize the esophagus all the way up to the thoracic inlet.
    Lymph nodes were harvested from the subcarinal space and sent as a
    separate specimen. The Penrose was tucked into the thoracic inlet. A
    28-French chest tube was placed through the 12 mm port site. The lung was
    seen to inflate under direct vision. The chest tube was secured with a
    heavy silk suture. Two other 5 mm port sites were closed with Monocryl
    and Dermabond.
    The patient was then flipped supine back onto a stretcher and then placed
    supine on the operating table. A footboard was placed at the feet, and
    the patient's double-lumen tube was changed out for a Nim size 8
    endotracheal tube. The patient had the subcutaneous probes placed for the
    Nim tube on the anterior chest. The patient was prepped from mandible to
    pubis. Dry sterile towels were used to score off where the neck incision
    would be and the abdominal part of the case. Ioban drape was placed,
    followed by the surgical drapes. After marking anatomic landmarks, a
    Hasson port was placed in the open technique in the RUQ. The camera was
    inserted and there was no evidence of adhesions or peritoneal implants.
    Under direct vision, an 11 mm port was placed in the left upper quadrant
    just lateral to midline. Two 5 mm ports were placed at each of the the
    costal margins. Another 5 mm port was placed far lateral on the right
    abdomen for the liver retractor. The liver retractor was inserted and
    placed under the left lateral segment of the liver and secured to the arm
    on the bed. The patient was noted to have a significant number of
    vascular structures along the lesser curve. It was quite possible that he
    had a replaced left hepatic. Some of these vessels were clipped and some
    were cauterized with the Harmonic scalpel. Dissection was carried over
    the top of the hiatus and down the left crura. The fundus of the stomach
    was then grasped as was the fat overlying the spleen and short gastrics
    were taken along the fundus. The beginning of the arcade of the
    gastroepiploic was identified and care was taken to stay away from this
    vessel. The descending colon was in close proximity to the stomach with
    some dense adhesions that were taken down with both blunt dissection and
    the Harmonic. The stomach was elevated off the pancreatic bed and more
    adhesions were taken down between the stomach and the pancreas. The
    stomach was mobilized laterally to the level of the pylorus. The pylorus
    could be grasped and elevated to the hiatus easily, signifying that
    adequate mobilization had been performed. The space underneath the
    esophagus was opened and more adhesions along the left crura were taken
    down. The left gastric was identified and an Endo-GIA vascular stapler
    was used to transect it. Next, the omentum was grasped and elevated
    cephalad and the ligament of Treitz identified. Approximately 40-50 cm
    from the ligament of Treitz, the bowel was tacked up to the anterior
    abdominal wall using an Endostitch device. A finder needle was placed
    through the anterior abdominal wall and into the bowel and air was
    insufflated into the bowel to ensure that the needle was in the lumen.
    The wire was then passed and it went easily. Over the wire, we then
    passed the introducer for the feeding tube. This was placed easily into
    the bowel and the feeding tube was then placed through the introducer.
    The feeding tube was attached to the anterior abdominal wall using nylon
    sutures and 3 more sutures were used to Stamm the bowel to the anterior
    abdominal wall. Next, the fundus of the stomach was grasped and, starting
    with a vascular load on the stapler, the conduit was created. Serial
    firings of the Endo-GIA stapler were then used to create the conduit. A
    small bleeding vessel along the lower border of the staple line was
    secured with an Endostitch. The specimen was then sewn to the tip of the
    conduit. The left neck was then opened using a 15 blade and this part was
    performed by Dr. The esophagus was identified and encircled
    with a Penrose drain. The nerve stimulator was used to identify the
    recurrent laryngeal nerve and make sure that it was not encircled with
    the esophagus. Blunt dissection was used to mobilize the cervical
    esophagus. Specimen was then brought up through the neck, bringing the
    conduit with it. This was done under direct vision to make sure that the
    conduit did not twist. There was plenty of conduit at the neck and the
    muscle of the esophagus was transected using a 15 blade. This allowed an
    extra 1 cm of mucosa to be taken for the anastomosis. An end-to-side
    anastomosis was performed. The gastrotomy was created and a 35 mm load of
    the Endo-GIA blue load stapler was used to create the posterior wall. The
    anterior wall was closed in a running fashion with Vicryl sutures. Prior
    to closing the anterior part of the wall, the nasogastric was inserted
    down through the stomach so it would sit near the xiphoid process. In the
    stomach, the conduit was pulled down so it would be straight. There was
    evidence of a small bleeding vessel along the right crura and this was
    clipped for control. Under direct vision, the liver retractor was removed
    and the EndoClose was used to close the 15 mm port site in the right
    lower part of the abdomen. Vicryl sutures were used to close the larger
    port sites fascia and Monocryl was used to close the skin. The neck was
    closed as per routine. A size 15 JP was placed into the neck
    and secured to the skin with nylon suture. At the end of the case,
    therapeutic bronchoscopy was performed to make sure that there were no
    secretions and the membranous portion of the trachea appeared normal. All
    needle, instrument and sponge counts were correct at the end of the case
    x2. The patient made 350 mL of urine and received 2900 mL of IV fluids.
    Total blood loss for the case was 150 mL.

  2. Wink mie operation
    I have read your thread about coding for a MIE and do not see any responses to your request. I too have posted the request and wondered if you had found any documentation that was helpful in billing this.

  3. Default Minimally Invasive Esophagectomy
    Quote Originally Posted by Coder708 View Post
    I am pulling my hair out any guru's who can help. I put Cpt codes that i came up with.. They may all be bundled.. ANY HELP I would so appreciate it

    PROCEDURES:
    1. Minimally invasive esophagectomy. CPT 43289
    2. Right thoracoscopy with mobilization of esophagus. CPT??????
    3. Laparoscopy with mobilization of stomach and creation of gastric
    conduit. CPT?????
    4. Placement of feeding jejunostomy tube. CPT 44015
    5. Botox injection of pylorus. CPT ????
    6. Left neck exploration and creation of end-to-side esophagogastric
    anastomosis. ??????? cpt
    7. Bronchoscopy. ?????? cpt

    DESCRIPTION OF PROCEDURE:


    - PREOPERATIVE DIAGNOSIS:
    Cancer of the gastroesophageal junction status post induction
    chemoradiotherapy.
    POSTOPERATIVE DIAGNOSIS:
    Cancer of the gastroesophageal junction status post induction
    chemoradiotherapy.
    DESCRIPTION OF PROCEDURE:
    The patient was brought to the operating room and placed initially supine
    on a stretcher. A thoracic epidural was placed, followed by Foley
    catheter, A line, and IVs. The patient was intubated and a double-lumen
    endotracheal tube was placed. Its position was confirmed
    bronchoscopically. The patient was then positioned prone on the operating
    table with care taken to pad his head and arms appropriately. The arms
    were abducted at the shoulder at 90 degrees and the elbows again were at
    90 degrees. The table was jackknifed at 25 degrees at the hips and a bean
    bag was rolled underneath his right side to elevate his chest. After
    prepping and draping the right chest in the appropriate fashion,
    landmarks were identified with a marker and a 5 mm stab incision was made
    just at the tip of the scapula. Insufflation was performed by inserting a
    Veress needle. A 5 mm port was placed followed by the 5 mm camera. There
    were no adhesions of the lung to the chest wall. A 12 mm port was placed
    in the anterior axillary line at approximately the fifth intercostal
    space and another 5 mm port was placed in the posterior axillary line at
    approximately the seventh intercostal space. Starting out with a hook
    cautery, the pleura was incised overlying the esophagus. The azygous vein
    was dissected free and an Endo-GIA stapler was used to transect it. The
    esophagus was encircled with a 5/8 Penrose drain which was stapled off
    with a blue load of the stapler. This Penrose drain was used as a handle
    to help mobilize the esophagus all the way up to the thoracic inlet.
    Lymph nodes were harvested from the subcarinal space and sent as a
    separate specimen. The Penrose was tucked into the thoracic inlet. A
    28-French chest tube was placed through the 12 mm port site. The lung was
    seen to inflate under direct vision. The chest tube was secured with a
    heavy silk suture. Two other 5 mm port sites were closed with Monocryl
    and Dermabond.
    The patient was then flipped supine back onto a stretcher and then placed
    supine on the operating table. A footboard was placed at the feet, and
    the patient's double-lumen tube was changed out for a Nim size 8
    endotracheal tube. The patient had the subcutaneous probes placed for the
    Nim tube on the anterior chest. The patient was prepped from mandible to
    pubis. Dry sterile towels were used to score off where the neck incision
    would be and the abdominal part of the case. Ioban drape was placed,
    followed by the surgical drapes. After marking anatomic landmarks, a
    Hasson port was placed in the open technique in the RUQ. The camera was
    inserted and there was no evidence of adhesions or peritoneal implants.
    Under direct vision, an 11 mm port was placed in the left upper quadrant
    just lateral to midline. Two 5 mm ports were placed at each of the the
    costal margins. Another 5 mm port was placed far lateral on the right
    abdomen for the liver retractor. The liver retractor was inserted and
    placed under the left lateral segment of the liver and secured to the arm
    on the bed. The patient was noted to have a significant number of
    vascular structures along the lesser curve. It was quite possible that he
    had a replaced left hepatic. Some of these vessels were clipped and some
    were cauterized with the Harmonic scalpel. Dissection was carried over
    the top of the hiatus and down the left crura. The fundus of the stomach
    was then grasped as was the fat overlying the spleen and short gastrics
    were taken along the fundus. The beginning of the arcade of the
    gastroepiploic was identified and care was taken to stay away from this
    vessel. The descending colon was in close proximity to the stomach with
    some dense adhesions that were taken down with both blunt dissection and
    the Harmonic. The stomach was elevated off the pancreatic bed and more
    adhesions were taken down between the stomach and the pancreas. The
    stomach was mobilized laterally to the level of the pylorus. The pylorus
    could be grasped and elevated to the hiatus easily, signifying that
    adequate mobilization had been performed. The space underneath the
    esophagus was opened and more adhesions along the left crura were taken
    down. The left gastric was identified and an Endo-GIA vascular stapler
    was used to transect it. Next, the omentum was grasped and elevated
    cephalad and the ligament of Treitz identified. Approximately 40-50 cm
    from the ligament of Treitz, the bowel was tacked up to the anterior
    abdominal wall using an Endostitch device. A finder needle was placed
    through the anterior abdominal wall and into the bowel and air was
    insufflated into the bowel to ensure that the needle was in the lumen.
    The wire was then passed and it went easily. Over the wire, we then
    passed the introducer for the feeding tube. This was placed easily into
    the bowel and the feeding tube was then placed through the introducer.
    The feeding tube was attached to the anterior abdominal wall using nylon
    sutures and 3 more sutures were used to Stamm the bowel to the anterior
    abdominal wall. Next, the fundus of the stomach was grasped and, starting
    with a vascular load on the stapler, the conduit was created. Serial
    firings of the Endo-GIA stapler were then used to create the conduit. A
    small bleeding vessel along the lower border of the staple line was
    secured with an Endostitch. The specimen was then sewn to the tip of the
    conduit. The left neck was then opened using a 15 blade and this part was
    performed by Dr. The esophagus was identified and encircled
    with a Penrose drain. The nerve stimulator was used to identify the
    recurrent laryngeal nerve and make sure that it was not encircled with
    the esophagus. Blunt dissection was used to mobilize the cervical
    esophagus. Specimen was then brought up through the neck, bringing the
    conduit with it. This was done under direct vision to make sure that the
    conduit did not twist. There was plenty of conduit at the neck and the
    muscle of the esophagus was transected using a 15 blade. This allowed an
    extra 1 cm of mucosa to be taken for the anastomosis. An end-to-side
    anastomosis was performed. The gastrotomy was created and a 35 mm load of
    the Endo-GIA blue load stapler was used to create the posterior wall. The
    anterior wall was closed in a running fashion with Vicryl sutures. Prior
    to closing the anterior part of the wall, the nasogastric was inserted
    down through the stomach so it would sit near the xiphoid process. In the
    stomach, the conduit was pulled down so it would be straight. There was
    evidence of a small bleeding vessel along the right crura and this was
    clipped for control. Under direct vision, the liver retractor was removed
    and the EndoClose was used to close the 15 mm port site in the right
    lower part of the abdomen. Vicryl sutures were used to close the larger
    port sites fascia and Monocryl was used to close the skin. The neck was
    closed as per routine. A size 15 JP was placed into the neck
    and secured to the skin with nylon suture. At the end of the case,
    therapeutic bronchoscopy was performed to make sure that there were no
    secretions and the membranous portion of the trachea appeared normal. All
    needle, instrument and sponge counts were correct at the end of the case
    x2. The patient made 350 mL of urine and received 2900 mL of IV fluids.
    Total blood loss for the case was 150 mL.
    I am fighting with this as well -- Medicare denies the open codes because of the laproscopic approach of the abdominal portion........but at least I can help with some of this -- The EGD w Botox injection of the pylorus is 43246, the lap feeding tube - 44186 I have been billing the 43289 - unlisted for the esophagectomies referring to the actual procedure done (43107,43112,43117,etc).....38589 - unlisted - according to Medicare for the lap lympandenectomy for both 38746 & 38747 (code only once)... and in this instance I would not bill the 31622, since it is only checking the positioning of the endotracheal tube.
    I will be anxious to see if anyone else has found any type of answer to this puzzle!!!

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