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Lap choly with lap appendectomy

  1. Default Lap choly with lap appendectomy
    Medical Coding Books
    Can these two be billed together with a mod 59 on the apepndectomy? Is the appendectomy considered incidental? The dx for it is 543.9 dialation. I thought I can, just wanted to make sure. Thanks!

    DESCRIPTION OF PROCEDURE: The patient was transported to the
    operating room and placed in the supine position. General
    endotracheal anesthesia was administered. The abdomen was prepped and
    draped in usual sterile fashion. The circulating nurse had called a
    surgical time-out. All members of the operative team were in
    agreement with that statement. Marcaine 0.5% with epinephrine was
    infiltrated into the inferior umbilicus. A vertical incision was made
    in the inferior umbilicus. The underlying fascia was grasped with
    Kocher clamps, opened for a short distance in the midline. The
    peritoneum was also opened for a short distance in the midline.
    Sutures of 0 Vicryl were placed through the fascia laterally. The
    Hasson cannula was inserted through the incision into the abdominal
    cavity. Sutures were tied around the cannula to create an airtight
    seal. A pneumoperitoneum was created with carbon dioxide to 15 mmHg.
    A 5 mm 0-degree laparoscope with attached camera was placed through
    the cannula. Initial inspection of the lower abdomen and pelvis
    revealed no significant abnormalities. The appendix was visualized in
    retrocecal position initially. The mid portion of the appendix
    appeared to be mildly dilated. The tip of the appendix was
    unremarkable. The patient certainly did not appear to exhibit acute
    appendicitis, although the mid portion of the appendix was somewhat
    dilated. The gallbladder was tense and distended in the upper
    abdomen. The stomach was decompressed. The liver appeared to exhibit
    some fatty change. Under direct visualization, a 5 mm trocar was
    placed in the epigastrium and two 5 mm trocars were placed in the
    right upper quadrant. Marcaine was infiltrated at each site prior to
    trocar placement. A long laparoscopic needle was used to attempt
    aspiration of the gallbladder. Only 20 mL of bile and several small
    stone fragments were aspirated. The fundus of the gallbladder was
    grasped and the gallbladder and liver were retracted superiorly.
    There were some adhesions involving the inferior surface of the
    gallbladder involving the greater omentum that were gently teased
    away. The infundibulum of the gallbladder was grasped and retracted
    laterally. The peritoneum was stripped away from the gallbladder and
    cholecystoduodenal ligament. There were also some inflammatory
    changes in this area. The cystic duct was identified as it exited the
    gallbladder and freed up for a few millimeters. A clip was placed
    across the cystic duct adjacent to the gallbladder. An opening was
    made in the cystic duct with microscissors. There were several small
    stone particles extracted from the cystic duct. Once there was free
    flow of bile, cholangiogram catheter was inserted under direct
    visualization through a separate trocar in the right upper quadrant.
    The cholangiogram catheter was inserted into the cystic duct and the
    duct was occluded around the catheter using 1 clip. Cholangiograms
    were performed with fluoroscopy. There were some small filling
    defects in the distal common bile duct. The common bile duct and the
    hepatic ducts were mildly dilated. There was very minimal flow of dye
    into the duodenum. There appeared to be at least a few stones in the
    distal common bile duct that were obstructing in nature. I attempted
    to flush these through the ampulla without success. The cholangiogram
    catheter was then removed. The cystic duct was occluded with 2 clips
    to not compromise the cystic duct-common bile duct junction. The
    cystic duct was transected. There were 2 branches of the cystic
    artery and each were dissected free adjacent to the gallbladder,
    doubly clipped and divided. Remaining peritoneal attachments off the
    inferior surface of the gallbladder were gently teased away.
    Electrocautery was used to dissect the gallbladder from the liver bed
    once sufficient distance was obtained away from the porta hepatis.
    Prior to division of the final peritoneal attachments, the liver bed
    was irrigated with saline. Hemostasis was strict. All saline was
    suctioned from the abdomen. The final peritoneal attachments were
    divided. The laparoscope with attached camera was placed through the
    epigastric cannula. An EndoCatch bag was placed through the umbilical
    cannula and the gallbladder placed into the bag. The bag, contents
    and cannula were all retrieved through the incision. The Hasson
    cannula was reinserted and pneumoperitoneum was reestablished. The
    appendix was again inspected. I elected to perform a laparoscopic
    appendectomy as there was some dilatation of the mid portion of the
    appendix. An opening was made between the mesoappendix and the
    appendix adjacent to the cecum. The appendix was divided at the cecum
    using the endoscopic GIA stapling device with 3.5 mm staples. The
    mesoappendix was divided using the endoscopic GIA stapling device with
    2.5 mm staples. The appendix was grasped with forceps through the
    umbilical clamp and the cannula, forceps and appendix all removed.
    The specimen was submitted for pathology. The Hasson cannula was
    again reinserted and pneumoperitoneum was reestablished. The abdomen
    was again inspected. Both staple lines were visualized. Hemostasis
    was strict. No other abnormalities or injuries were noted. Remaining
    cannulas were removed under direct visualization. The
    pneumoperitoneum was decompressed. The fascial incision at the
    umbilicus was closed using interrupted sutures of 0 Vicryl.
    Subcutaneous tissues were irrigated with saline. All skin incisions
    were closed using subcuticular sutures of 4-0 Vicryl. Dermabond was
    applied. At the completion of the procedure, all sponge, needle and
    instrument counts were correct. Estimated blood loss was 20 mL. The
    patient tolerated the procedure well and was transported to the PACU
    in stable condition.

    Here is what I have:

    Thanks a lot!

  2. #2
    Milwaukee WI
    Default 44955
    I would consider the appendectomy as "when done for indicated purpose at time of other major procedure." The surgeon clearly states the reasons why s/he felt the appendix needed to be removed (i.e. it was not just incidental), so I would use the add-on code CPT 44955.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    I think you were right the first time - 44970 is correct for a lap appy for cause during another laparoscopic procedure. See NCCI narratives. Since the narratives are only updated once a year, they're still Version 16.3. Page VI-9, or F.5. under Laparoscopy in the 40000's rules.

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