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abdominal abscess and revision of hartmanns procedure

  1. Default abdominal abscess and revision of hartmanns procedure
    Medical Coding Books
    Please advise with proper codes. Thanks in advance!!!

    PREOPERATIVE DIAGNOSIS:
    1. Abdominal wall abscess.
    2. Peritoneal abscess with suspected Hartmann pouch disruption.

    POSTOPERATIVE DIAGNOSIS:
    1. Abdominal wall abscess.
    2. Peritoneal abscess with Hartmann pouch disruption.

    OPERATION PERFORMED:
    1. Incision and drainage of abdominal wall abscess with removal of abdominal
    wall mesh and abdominal wall reconstruction using xenograft mesh.
    2. Incision and drainage of peritoneum with large-bowel resection.

    ANESTHESIA:
    General plus local.

    DESCRIPTION OF OPERATION:
    The patient is on therapeutic IV antibiotic. DVT prophylaxis consisted of
    subcu heparin and pneumatic compression stockings. The patient was placed
    under general anesthesia after informed consent was obtained. An orogastric
    tube and Foley catheter were placed. The abdomen was prepped and draped in the
    usual fashion. The left upper quadrant ostomy was left open. The ostomy bag
    was covered with an impervious plastic drape prior to the prep. Next, an
    oblique incision was made over the previous left groin incision. Immediately
    underneath the subcu tissue, there was foul-smelling anaerobic abscess
    collection. Aerobic and anaerobic cultures were obtained. The area was
    irrigated profusely with saline and Dakin solution. The abscess cavity was in
    continuity with existing chronic mesh. This was taken down by careful sharp
    dissection. The cord structures were granulated and were left alone. After
    the mesh was removed, reconstruction was performed using Cook biologic
    xenograft mesh and running PDS suture. The wound was irrigated with additional
    saline. A Jackson-Pratt drain was placed over the mesh and brought out through
    the left lower quadrant. The wound was closed with running interrupted Vicryl.
    The skin was left open.

    Next, a midline incision was made in the lower abdomen. The lower pelvis was
    entered. An abscess cavity was found in the left lower quadrant. This was
    also anaerobic in gross appearance. Cultures of this were obtained and labeled
    "peritoneum." At the base of the abscess cavity, the Hartmann pouch was easily
    mobilized and its staple line was seen to be disrupted. Two inches of Hartmann
    pouch was prepared and divided with the firing of a GIA stapler and oversewn
    with Vicryl Lembert sutures. The abdomen was irrigated with additional saline
    and a drain was placed at this location of the abscess cavity, exiting the
    abdomen in the right lower quadrant. The abdominal wall fascia was closed with
    running looped #1 PDS. The subcutaneous tissues were reapproximated with
    running Vicryl. Portions of the wound were closed with staples. Portions were
    left open. The open wounds in the left lower quadrant and the midline were
    then packed with Betadine gauze. The patient tolerated the procedure well.
    All needle, sponge, and instrument counts were correct x2.

  2. #2
    Default
    There are no CCI edits with this senario. And thats in order of greatest RVU.

    49020
    44604-m-51
    15420-m-51
    +11008
    10180-m-51

    MS
    Last edited by surgonc87; 11-16-2011 at 11:38 AM.

  3. Default
    Thanks I really appreciate your coding advice!

  4. Default
    Previous coding is incorrect. My suggested would be:

    49020
    11008
    49568
    10180

    Previous code errors:
    44604 is an orraphy - Dr did resection with anas.
    44604 is bundled into 49020 as is 44140
    15420 - is considered a prosthesis which is part of 49568 "or other prosthesis" 49568 is an add-on to 11008 per guidelines in CPT.

    Bests

  5. #5
    Default
    Opps Encoderpro mislead me. There is an edit with 49020 & 44604, thereby, 49020 is more advantageous to report.

    also your coding error pertains to (15420 - is considered a prosthesis which is part of 49568 "or other prosthesis" 49568 is an add-on to 11008 per guidelines in CPT. )--check the guidelines again.

    Coding is ambiguous, so its not exactly correct to say others are wrong and you're always right.


    Quote Originally Posted by Lujanwj View Post
    Previous coding is incorrect. My suggested would be:

    49020
    11008
    49568
    10180

    Previous code errors:
    44604 is an orraphy - Dr did resection with anas.
    44604 is bundled into 49020 as is 44140
    15420 - is considered a prosthesis which is part of 49568 "or other prosthesis" 49568 is an add-on to 11008 per guidelines in CPT.

    Bests
    Last edited by surgonc87; 11-16-2011 at 01:58 PM.

  6. #6
    Location
    Fayetteville, NC
    Posts
    300
    Default
    What about:
    49020
    44604-59
    15400
    11008
    10180

    15420 is for face, scalp, neck, ears, orbits, genitalia, hands, feet, &/or multiple digits per CPT.
    15400 is for trunk, arms, legs per CPT.
    The closure for the Hartmann pouch to me does not seem to be directly related to the abscesses (there is no definite link made) and therefore can be coded with a -59 for separate procedure.
    The modifiers would actually depend on what the previous abdominal procedure was and whether or not a global from it applied. The -59 would still apply to 44604 but might be a secondary modifier depending on whether or not the patient is in a global.
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

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