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Thread: Rosie, CPC

  1. #1

    Default Help with coding takedown of colostomy

    AAPC: Back to School
    Could I get some thoughts on coding this op report? Here is the scrubbed report. Pre and Post Operative Diagnosis: 1. Unwanted Colostomy 2. Ventral Hernia
    Operation Performed: 1. Exploratory Laparotomy. 2. Reconstruction of the abdominal wall. 3. Takedown of colostomy. 4. Mobilization of splenic flexure. 5. Coloproctostomy with EEA stapled anastomosis.

    Abdomen was clipped, the ostomy sutured closed. The epithelialized scar tissue in his midline was excised in its intirety. This involved stripping some adhesions between the small bowel and the scar tissue. These were present and troublesome but not impossible. All his small bowel was somewhat adhesed together, but the adhesions were not dense, and they certainly were not vascular. The entire midline skin was excised including the subcutaneous fibrous tisse and the peritoneum. An Omni-Trace retractor was then placed to expose the abdomen. The ostomy was left intact at first while adhesions were taken down. Extensive adhesiolysis occurred including into the upper quadrant proximal to its colostomy where the splenic flexure was mobilized. The mesentery was freed up, and the colon was straightened out, starting at the distal transverse colon. The pelvis was dissected using a lot of blunt dissection but a fair amount of sharp dissection as well down into the pelvis where the rectum was well buried Eventually, in order to tease the rectum separate from the bladder and separate from the lateral pelvic wall, we passed a PEA dilator into the rectum and used that to push up on the rectum which tremendously facilitated freeing up the rectum. Sharp and blunt dissection was used to eventually free it up enough to at least see the dome of it anteriorly. The colon was then freed up at the ostomy site using blunt and sharp dissection. The ostomy incision was made vertically in an elliptical fashion. The colon was freed up and dropped into the pelvis and appeared to have excellent length without any tension whatsoever. A noncrushing clamp was placed proximally was placed proximally and the colon divided just proximal to the ostomy. The anvil for the 29 mm EEA was then placed in the distal colon. A pursestring of 4-0 Prolene was used to secure the anvil in the colon. The EEA was then placed in the rectum and bimanually maneuvered into a position pointing slightly anteriorly. The spike was extended, and the anvil attached to it. The colon was brought down to the pelvis and inspected for any twisting. The EEA was fired and the donuts inspected. They were intact. The noncrushing clamp was left on the descending colon, and the rectum was insufflated with air with irrigation fluid in the pelvis. No bubbles were noted. The ostomy was closed in 2layers with heavy Vicryl. The interior layer was placed under direct vision prior to mobilizing all the fascia. The skin was then elevated from the scar tissue at his midline completely around the incision. The fibrous tissue and hernia sac were then excised from the fascia, and the peritonem was resected with it. The fascia then was able to be approximated in the midline and closed primarily with running double-stranded PDS. This produced a little bit of tension but not anything really unsatisfactory. Some reinforcing PDS sutures were used as well. The ostomy was then closed from the outside with another running #1 Prolene. Irrigations were carried out. A drain was placed in the subcutaneous tissue and exited through the skin laterally on the left. The skin was everted with nylon sutures in a mattress fashion, and then the remainder of the skin incision was closed with staples.

    Any help would be apprecited.
    Last edited by rosalyn reis; 06-22-2011 at 05:05 PM.

  2. #2
    Join Date
    Apr 2007
    New Delhi, India


    I would code this scenario as 44626. I am wondering if we can append mod 22 for extensive freeing of bowel and rectum from adhesions, though the provider has not specified extra time for this. Others' opinion is requested.
    Girish Dadhich, CPC

  3. #3
    Join Date
    Apr 2007
    Greater Orlando

    Default 44626

    I agree with 44626. My experience with modifier "22" is that the provider must specify exactly what made this procedure above and beyond the "norm" in 80 characters or less. They must say what is normal and how long or with what special skills they have that require special consideration. I wouldn't advise it for this one. Sorry. I think it's a straight up 44626. Thanks.
    Anita Johnson, CPC, CCS, CPMA, CCS-P
    Orlando, FL

  4. #4

    Smile Coding help

    Thank you both for your help. I really appreciate it. Rosie

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