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Thread: Help with surgery

  1. #1

    Default Help with surgery

    AAPC: Back to School
    I am needing some guidance please on the CPT codes for the following
    What I am possibly thinking is 44626, 44310, and 44139? But not sure if these are at all correct. And am confused on how I can use 44139 cause it says in conjunction with codes 44140-44147? The lysis would be bundled. Here is the op note. Sorry kind of long. I appreciate any responses. Thanks

    Takedown of colostomy with low colonic stapled anastomosis, mobilization of splenic flexure, lysis of adhesions, extensive; creation of diverting loop ileostomy

    PROCEDURE: The abdomen was entered through a vertical midline incision, excising the previous skin cicatrix. Upon entering the abdomen, extensive adhesions were identified. These were taken down until the bowel was free from the anterior abdominal wall with the exception of the ostomy. The adhesions
    were quite extensive and adherent to the pelvis and required lysis of adhesions from the ligament of Treitz to the terminal ileum in order to free up the small bowel from the colon adequately enough to find what was felt to be the rectal stump. The dissection was continued around the rectal stump until adequate exposure was felt to have been obtained. The extensive adhesions required almost two hours of lysis in order to get to this point in the operation. The operation continued with takedown of the colostomy, which had been sewn closed prior to the procedure. An ellipse of skin was taken around the colostomy and down to the fascia. The ostomy was freed from the fascia and then brought into the operative field into the abdominal wall. Initially, there was felt to be adequate length for an anastomosis at this point. The ostomy was excised and the edges
    freshened. A pursestring suture of 3-0 Prolene was placed and then the anvil of an EEA stapling device was then placed into the proximal bowel and the pursestring suture was tied. Distally, the bowel was dilated cautiously with the sizers and subsequently a 31 EEA stapler was introduced and then after what was felt to be adequate visualization, the anvil was advanced into the pelvis and then secured to the proximal bowel by snapping the anvil in place. The stapler was then tightened and then fired. The resulting visualization of the stapler showed that there were actually two concentric rings of bowel. Cautious insufflation, however, revealed a massive leak of air and it was subsequently identified that this was distal to the anastomosis and quite extensive. The dissection was continued, completely freeing up the bowel and the distal lumen once again and a stapler, GIA in nature, was placed across the distal pouch and fired once again and then the pursestring suture was reapplied proximally and at this point a 29 EEA stapling device was placed with the anvil in the proximal bowel and the distal bowel being manipulated with the stapler and then the anvil passed through what was felt to be the closed stump and fired once again. This also resulted in significant leakage. The bowel was completely disrupted at this point in time to aid in exposure at the level of the anastomosis. The subsequent hole was found and completely closed with interrupted figure-of-eight sutures of 3-0 silk, completely closing the distal stump. At this point in time, the proximal bowel was freed once again and due to the repeated nature and scar tissue in this area, it was felt that the mobilization of the proximal bowel would be required. The bowel was contained to avoid any leakage and the entire splenic flexure was mobilized with the use of the harmonic scalpel until adequate exposure and length could be attained. At this point, due to several attempts at the pursestring suture and failure apparently at this level, the 29 anvil was passed into the lumen of the proximal bowel and then a TA stapling device was placed across the end of the bowel completely closing the proximal bowel at this level. The stapler was then advanced through a small puncture wound, well away from the closure, and then the 29 EEA stapling device was then passed through the distal stump, which had been sewn closed, and then the anvil and the stapler were connected and then tightened and after assuring adequate positioning, these were fired. Once again, this seemed to be somewhat tenuous but repeated air check and actual colonoscopy revealed the anastomosis to be intact with no evidence of leakage. The bowel clamps were all removed and the abdominal cavity was irrigated vigorously at this point. Due to the multiple attempts at this anastomosis distally and concern over its potential leakage if left unprotected, a right upper quadrant loop ileostomy was fashioned with the distal ileum being brought out through a circular incision and held in place with the skin bridge. The ostomy appliance hardware was then applied underneath the skin bridge and an umbilical clip was then applied across the mesenteric surface of this portion of the ileum and this was left in place to be vented later. The abdominal cavity once again being irrigated and then the fascia was closed with running number 1 Prolene suture. The fascia of the previous ostomy site was also closed with running number 1 Prolene suture. The subcutaneous tissue was irrigated in both of these wounds with Betadine and then further irrigated with saline to cleanse out the Betadine. The deep tissue was approximated in the ostomy site with Vicryl suture and the skin was closed in both of these incisions with skin clips.

  2. #2


    does anyone have maybe any suggestions please? I'm just really needing help with this one. Or even pointing me to any resources would be great too. Thanks

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default I'm not expert at this

    I struggle with bowel surgery all the time.

    I think you are okay. I'm thinking the patient had a previous colectomy (resulting in the colostomy), so I would try the +44139. You might get a denial and have to supply the op note to clarify.

    The surgeon mentions "extensive lysis of adhesions" but doesn't really give any more detail. We ask our surgeons to describe the lysis in more detail and specifically state the amount of time the spent on this before they could get to the primary procedure. If it's and hour or more, we will append a -22 modifier.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4


    yes it does thank you for your help.

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