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Need CPT help for OP note-I can really use

  1. #1
    Default Need CPT help for OP note-I can really use
    Medical Coding Books
    I can really use some experts on this one. He said he did: exp lap, reduction of intussuption, colon resection with Hartmann procedure. Thanks!

    PREOPERATIVE DIAGNOSIS: Left colon tumor with obstruction secondary to intussusception.

    POSTOPERATIVE DIAGNOSIS: Left colon tumor with obstruction secondary to intussusception. Probable villotubular adenoma with malignant change.

    PROCEDURE: Exploratory laparotomy with sigmoid colon resection and Hartmann procedure.

    SURGEON: xxxxxx

    ANESTHESIA: General endotracheal.

    INDICATIONS: The patient is a 55 year old female who has undergone chronic GI problems related to constipation over the past several months. She recently presented to the emergency room with a prolapse of the rectum, and a large fleshy tumor, with some firm areas noted, and the intussusception was partially reduced manually per rectum.
    She was admitted to the hospital and underwent a CT scan which did show evidence of an intussusception of the rectosigmoid. There was no evidence of metastatic disease. These findings were discussed with the patient and her family. I felt that exploratory laparotomy with resection of the polyp or malignancy was advisable and because of the unprepped colon a sigmoid colostomy and Hartmann pouch would be advisable. I discussed the procedure, including risks and details with the patient and her family. Opportunity for questioning was offered and there was none forthcoming.

    PROCEDURE IN DETAIL: Therefore the patient was taken to the operating room and after satisfactory induction of general endotracheal anesthesia the abdomen was prepped and draped in the usual fashion after a Foley catheter was placed. After appropriate time out a midline incision was made and carried down through the subcutaneous tissue to the midline fascia which was opened. The small bowel was moderately distended and this was removed from the abdomen. Exploration was then carried out and a long tubular segment of sigmoid colon was intussuscepted all the way to the deep pelvis. This was gradually reduced and once the colon was allowed to be completely freed from the intussusception a large polypoid mass was noted. The bowel looked completely normal. There was no evidence of necrosis, although it was chronically dilated, certainly no inflammation or peritonitis was present. The normal appearing distal bowel was inspected and a suitable location for transection distally was made. A GIA stapling device was passed through a small fenestration and transverse closure was then carried out in the bowel. The bowel segment was further mobilized and a small serosal tear was included in the resection. Stapling device was placed transversely proximally to this lesion, approximately 12 inches of bowel was removed, a large wedge of mesentery was used to completely resect this bowel. Inspection showed no evidence of bleeding. Manual exploration of the abdomen showed a small cystic lesion on the surface of the liver, however the rest of the liver was entirely negative. There was no evidence of metastatic disease within the abdomen after careful inspection. The small bowel was returned to the abdomen and after brisk irrigation with antibiotic solution the abdomen was closed with running #1 PDS suture. Prior to this a suitable site for the colostomy was chosen and a small button of skin was removed, an X-shaped incision was made with electrocautery into the abdomen. The cut end of the colon was easily passed through without tension, and rested easily upon the abdominal wall. With irrigation of the abdomen completed and it being closed, the skin and subcutaneous tissue was irrigated with antibiotic solution and closed with skin staples. The colostomy was immediately matured with resection of the staple line and sutured to the skin with 3-0 chromic suture placed in simple fashion. The stoma bled quite readily and looked quite healthy and a colostomy bag fixture was applied. The patient tolerated the procedure well. Blood loss was minimal. She was sent to the recovery room in satisfactory condition.

  2. #2
    44141 coloectomy partial; w/ skin level colostomy
    44139 Mobilization (take-down) of splenic flexure performed in conjuction w/ partial colectomy (I'm not sure about this code, but my coding software advises me to use this code as well).
    Now I'm new to general surgery and do not have a coding companion for general surgery, so this is an educated guess. I'm still learning these procedures myself. I do know that the exp lap is included.
    If someone else comes up w/ something else, can you please put the rationale on here?

  3. #3
    Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) 44143.

    Unfortunately you can't add 44139 on to this code.

  4. #4
    Default Thanks for posting.
    This is defiantly one I'll be printing for reference.

  5. Smile

    This can be coded with 44143 & 44139

    Joseph Amalraj Antonisamy CPC-H

  6. #6
    Thank you!

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