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Perforated sigmoid diverticulitis with intraperitoneal abscess

  1. Default Perforated sigmoid diverticulitis with intraperitoneal abscess
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    Patient had a exlporatory lapratomy and parital sigmoid colectomy with sigmoid stoma and hartmann pouch.

    Procedure Note:
    Pt was taken to the operative suite and placed in the supine position. Upon satisfactory general anesthesia, the patient's abdomen was prepped and draped in a sterile fashion. Midline incision was carried out from the umbilicus down to the pubic symphysis. Dissection was carried down sharply using the scalpel. The peritoneal cavity was entered under direct vision. Immediately upon entering the peritoneal cavity, purulent peritoneal fluid was encountered, culture taken. Peritoneal cavity was irrigated. All irrigant was suctioned free. The patient was found to have a dense inflammatory mass between the proximal sigmoid colon, which was folded down and locally adherent into the pelvis along the left lateral pelvic side wall. Using blunt dissection, the inflamed segment of sigmoid colon was delivered in the operative field. She was found to have an obvious site of perforation measuring about 2.5 cm in diameter. Proximally, a site was chosen for transection of the proximal sifmoid and this was carried out with the GIA stapling device. The intervening sigmoid mesentery was divided between clamps and tied with 0 silk. A site was chosen distal to the performated segment for transection of the sigmoid using the GIA stapling device. The perforated segment of sigmoid colon was removed from the operative field and sent to Pathology. Peritoneal cavity was irrigated. All irrigan was suctioned free. The lateral peritoneal attachment of the descending colon was incised using Metzenbaum scissors. This was to afford adequate length of the proximal segment, which was to be exteriorized as an end sigmoid stoma. Circular incision was carried out in the skin at a midpoint between the umbilicus and the left anterior superior iliac crest. Dissection was carried down sharply using the cautery. A cruciate incistion was carried out in the anterior rectus fascia. Bluntly, the left rectus abdominis muscle was entered and retracted midially and laterally. The end sifmoid was brought through the stoma site. Then 3-0 silk sutures were used to attach the anterior fascia to the seromuscular layer of the sigmoid colon.

    Attention was turned to the operative incision. The working incision was closed with a running #1 Prolene suture. The skin was left open and a #1 Penrose drain was placed along its entire length. The skin was closed loosley with 2 separate 4-0 silk vertical mattress sutures. Topical dressing was applied.

    The stoma was then matured to the skin. Metzenbaum scissors were used to cut out the GIA staple line. The maturation down to the skin was carried out with circumferentially placed 4-0 Vicryl sutures. The stoma was somewhat flat at the skin surface but grossly appeared to be viable. A stoma appliance was placed.

    Im coming up with 4900 exploration of abdomen and 44141 colectomy partial;with skin level cecostomy or colostomy. Do you agree?

  2. #2
    Post 49000 bundled

    I would code it just 44143, it's a Hartmann type procedure. Code 49000 is bundled as per CCI edit.

    Girish Dadhich, CPC

  3. #3
    Default 44143
    I agree with 44143
    Anita Johnson, CPC, CCS, CPMA, CCS-P
    Orlando, FL

  4. #4
    49000 is a "separate procedure" and cannot be billed with other major open procedures of the abdomen. See NCCI documents.


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