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Seriously stumped please help

  1. #1
    Fayetteville, NC
    Default Seriously stumped please help....SOLVED:)
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    OK I have looked everywhere for the CPT code(s) for this and can not find what I'm looking for:

    Exploratory laparotomy with repair of aortic duodenal fistula, repair of aortic wall, insertion of arterial line catheter for monitoring. I do know the arterial line part it's the rest of it that's got me stumped

    Patient has a 7 cm approximately in diameter abdominal aortic aneurysm which had eroded into the third portion of the duodenum near the bifurcation to the iliac vessels.

    Does anyone have any ideas on this?
    I will post the OP note Monday
    Last edited by Grintwig; 09-14-2010 at 02:16 PM. Reason: Bad spelling....

  2. Default
    Have you looked at codes 34800-34826? These repair with a prosthesis which you don't mention.

  3. #3
    Fayetteville, NC
    I looked at them but this was open and he used Floseal and Bio-A but not the type of prosthesis that those codes call for. Thank you anyway

    Here's the OP note maybe this will help.

    Description of Procedure:
    The patient was already in the operating room under general endotracheal anesthesia for the previously done EGD and central line procedure. The endoscope was reinserted because of persistent bleeding at the conclusion of the case noted from his NG tube and also refluxing up to his mouth. The endoscope was noted to find a significant amount of bleeding coming from the third portion of the duodenum back towards the pylorus and into the antrum of the stomach. The abdomen was then prepped and draped in standard fashion. A midline abdominal incision was made. Underlying soft tissues were divided with electrocautery. Lysis of adhesions was then performed to separate the small bowel because of a prior gunshot wound and multiple surgeries that had been performed related to that injury. Next, there was one small enterotomy made in the small bowel during lysis of adhesions, repaired with 3-0 Vicryl suture and then oversewn with interrupted 3-0 silk suture. Once the adhesions were separated and the contents of small bowel was then pushed back to the stomach which were aspirated with Levine tube. The duodenum was mobilized towards the midline as well. The patient was noted then upon inspection of the third portion of the duodenum that it was adherent to the aorta. Initially a soft tissue mass was felt in the lumen of the duodenum in this area but upon palpation it was noted to have a central defect and was directly over the aorta and noted to be consistent with of the aortic duodenal fistula. The thrombus and plaque from the aorta was extending up into the duodenum. Next, the dissection was taken to mobilize aorta to obtain proximal control. This was done by first mobilizing the right renal vein where it crosses the aorta and then we divided the vein between 0 silk suture ties and 2-0 silk suture ligatureson either side of the vessel which was then divided with Metzenbaum scissors. Next the aorta was palpated and it was noted that the aorta was very broad and there was concern for an underlying aneurysm. It was measured and was approximately 7 cm in diameter. A DeBakey clamp was then used to occlude the aorta proximally. Once the source of bleeding from proximally was controlled, the aorta was cleared of overlying soft tissue the fibrinous tissue between the small bowel and the aorta was cleared circumferentially. Next, a Satinsky clamp was placed partially occluding the aorta and also to allow removal of the aortic connection to the small bowel. The aorta was then incised with a scalpel, removing the anterior wall of the aorta with a portion of the small bowel. Next, the aortic defect was oversewn in 2 layers with a running 2-0 Prolene suture and then the Satinsky clamp removed. The proximal clamp was removed as well. FloSeal was applied to the aortic repair and then this area was also covered with a piece of Bio-A which remained in the area once the bowel was placed back over it. The small bowel was dilated in that area and it was therefore able to be closed primarily with a TA-60 stapling device and oversewn with a 3-0 Vicryl suture. The fistula tract was sent to the lab for evaluation. Next, the abdomen was thoroughly irrigated. There is concern that the patient is entering DIC as his fluid was becoming very thin and he was having some sources of serosanguineous fluid collections within the abdomen. Abdomen was irrigated and the fascia of the anterior abdominal wall was closed with a #1 looped PDS suture. Skin edges were closed with skin staples.

    Hopefully that will help. My real issue is I cannot find a single procedure to cover this. I have found several that have some elements of this but they also contain elements that this procedure does not have. If I use an unlisted code how do I figure out what to charge as there really isn't a comparable procedure. Unless I overlooked it

  4. #4
    Fayetteville, NC
    Also an EGD was done prior to this procedure. The EGD is the reason why he went on to do this procedure. Am I correct in thinking unless there were other results for the EGD besides the bleeding that we cannot charge for this?

  5. #5
    Fayetteville, NC
    Default Yay!!
    After consulting with the surgeon and reviewing codes this is what we came up with:

    35221 for the repair of the blood vessel in the abdomen
    with a DX code of 441.5
    44650-51 for the closure of the small bowel fistula
    with a DX code of 569.81
    Also the EGD 43239-59
    with a DX code of 578.9
    And the arterial line 36620-59
    with a DX code of 577.0

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