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Thread: how to code a rt colon resection

  1. #1

    Default how to code a rt colon resection

    AAPC: Back to School
    Sometimes it's confusing to me on rt colon resections because the code 44160 includes removal of terminal ileum or part of and the doctor does not always remove any of the terminal ileum. If anyone could look at the this operative report and path and tell me how you would code it I would appreciate it

    Operative report:
    DETAILS OF SURGERY: Patient was brought into the operating room,
    placed in supine position, received anesthesia. Abdomen was
    prepped. We made a midline incision through skin, subcutaneous
    tissues, fascia, entered the abdominal cavity. We mobilized the
    right colon all the way over to the middle colic vessels. We
    divided the colon just to the right of the middle colic vessels,
    carried our dissection down the mesentery to the ileocolic
    vessels. We then divided the terminal ileum and carried our
    dissection of the mesentery up the inferior aspect, paying
    particular attention to the position of the ureter and the
    duodenum at all times. We placed clamps across the ileocolic
    vessel and divided that structure, oversewed it using a figure-of-
    eight Vicryl stitch. We then closed the mesenteric defect with 3-
    0 Vicryl interrupted sutures and did a hand-sewn end-to-end
    anastomosis using 3-0 Vicryl interrupted sutures. We checked the
    anastomosis, found no evidence of leakage and no evidence of
    ischemia. We then irrigated and obtained hemostasis. We closed
    the midline fascia with #1 looped PDS, closed the skin with
    surgical staples, placed sterile gauze and paper tape over that.
    The patient tolerated procedure well.

    path report
    Colon, right, resection:
    - Tubular adenoma, 2.5 x 2.5 cm.
    - No in-situ or invasive carcinoma identified.
    - Unremarkable appendix.
    - Shave resection margins free of adenomatous change.
    - Seventeen lymph nodes; no metastatic carcinoma identified (0/17).
    COMMENT: The diagnosis rendered is based upon gross and microscopic
    CLINICAL HISTORY/DX: 76-yr-old male with history of prostate cancer.
    For colon resection.
    1. Right colon
    Received is a container labeled with the patient's name and "1 right
    colon". Present in the container is a specimen consistent with the
    label. The bowel has been previously opened. The colon measures 27 x
    3.5 x 2.5 cm. A moderate amount of adipose tissue is present. Both
    margins are open. The small bowel has a length of 3.5 cm. Identified
    4 cm. from the ileocecal valve and 20 cm. from the distal margin is a
    sessile polyp which has been previously sectioned into. The polyp
    measures 2.5 x 2.5 cm. The adipose tissue is removed and placed in
    Dissect-Aid. The appendix has a length of 4.8 cm. and ranges in
    diameter from 0.5 to 0.7 cm. Sectioning the
    appendix reveals no gross lesions. The sessile polyp is pinned to wax
    for fixation. Sectioning reveals no invasive tumor grossly. No
    additional polyps, masses or diverticulosis is appreciated. Summary of
    sections: "1A" - proximal margin, "1B" - distal margin, "1C" -
    appendix, "1D" - "1H" - sessile polyp, "1I" - "1K" - small nodes

  2. #2
    Join Date
    Apr 2007


    Terminal illeum definition is just the distal part of the small intestine. 44160 is correct per operative note. If doctor does not mention anything about taking/ dividing terminal illeum or illeocecal valve, then it would just be 44140


  3. #3
    Join Date
    Apr 2007


    44160 is correct

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