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Thread: surgery help for an exploratory lap with intravenous pyelogram and colostomy coding

  1. #1
    Join Date
    Apr 2007
    Des Moines

    Default surgery help for an exploratory lap with intravenous pyelogram and colostomy coding

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    The patient came in for an ER visit and then went straight to surgery- the doctor states his visit as a consultation after he came to the ER and had CT's done. So can I code the consult if the hospital already billed the ER visit? And do I need to put a 57 modifier on that for surgery the same day? And do I not code the exploratory since it was converted into an open procedure?

    Here's the procedure note for the rest of it that I'm unsure how to code and there's a second surgeon involved too.

    "...A 5mm optiview port was inserted infraumbilically and pneumoperitoneum was obtained. Prior to insufflating anything the camera was inserted and no evidence of free air in the abdomen was present. Insufflation was undertaken and following this there was clearly some retroperitoneal gas present with gas dissecting up along the retroperitoneal and extraperitoneal plane in the pelvis to a small degree. There was no blood evident. There was about 10cc'c of clear serous type fluid in the pelvis which initially gave me concern for a genitourinary tract injury. There was no evidence of an intraperitoneal entry and teh rectum was examined all the way down to the peritoneal reflection and there was no sign of injury. Intravenous pyelogram was then completed. Multiple views following contrast all the way from thekidneys down to the bladder were donew ith the foley clamped and unclamped. These were interrupted intaoperatively by r. Powers and no evidence was present for a genitourinary tract injury. Rectal exam under anesthesia was then completed with the Hill-Ferguson retractors and was unable to reach the area where the suspected injury was so it was no amenable to a transanal closure. Given that it was elected to perform a diverting sigmoid colostomy. Presacral drainage was deferred given the penetrating nature of the injury and the lack of evidence showing a benefit of presacral drainage. Sigmoid colon was not very mobile and the white line was incised sharply with scissors and mobilized medially. The left ureter was examined and no evidence of problems were seen and once adequate medial mobilization was completed for loop sigmoid colostomy to be formed. All of this was done with the aid of a 5 mm port in right lower quadrant and a 10mm port in the left lower quadrant at the anticipated site of the ostomy. The sigmoid colon was grasped through the 10mm port at the site of the ostomy, the pneumoperitoneum was desufflated and the two 5mm ports were removed. The incision was widened in a circular fashion around the 10mm port site. The fascia was widened and teh rectus muscles was split and the posterior fascia and peritoneum were opened wide enough to allow adequate space for the loop colostomy and this was delivered through the incision ensuring no twisting of the mesentery. The mesenteric opening was then created and a 24 French chest tube was passed through this to create a bar to elevate the colostomy. The bar was secured with a 2-0 Prolene sutures, the incisions were closed, the colostomy was matured. Colostomy appliance was placed.

    Any advice on the direction where to go or what I can even code for?


  2. #2
    Join Date
    Apr 2007
    Des Moines


    I'm not sure if this is right and the physician wanted it coded asap so I came up with 99254- although I doubt this pays because it sounds like there was an ER visit prior to the consult... only I don't get those reports. Then I came up with 44188 and 74400 with 863.45 for the DX- extraperitoneal rectal gunshot wound.... did the E-code with the consult...

    any thoughts yet?

    Thank you

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