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colostomy help for op note

Carol Posted Mon 03rd of January, 2011 16:47:17 PM

I know this is long but I am very confused on revisions and take downs of colostomy-any help is appreciated thank you

PREOPERATIVE DIAGNOSIS: Colostomy stricture.

POSTOPERATIVE DIAGNOSIS: Colostomy stricture secondary to tight fascial opening and small bowel adhesion at the level of the colostomy.

TITLE OF OPERATION: Sigmoidoscopy followed by colostomy revision with partial left colectomy and completion sigmoidoscopy.

CLASSIFICATION: 4 INDICATIONS FOR PROCEDURE: The patient is a frail elderly 85-year-old woman who had undergone emergency laparotomy for ischemic colitis. She had done well initially but failed to have colostomy output and was having increasing abdominal pain. Abdominal x-rays documented relative obstruction of the level of the fascia with large amount of impacted stool. She was brought to the operating room for exploration of the colostomy.

OPERATIVE FINDINGS: Included an apparent tight fascial opening. I was unable to actually pass a rigid sigmoidoscope through the colon at the level of the fascia. Once the colostomy had been mobilized, it became apparent that not only was the fascial opening somewhat tight but there was a small bowel loop impinged on the colon at the level of the fascia. At the completion of the procedure, the fascial opening was generous and sigmoidoscope passed nicely to 15 cm.

DETAILS OF THE PROCEDURE: The patient was brought to the operating room and placed in supine position. Following IV sedation, she initially underwent sigmoidoscopy through the colostomy. The stoma was gently probed initially with surgeon's finger. There appeared to be a tight fascial opening at this level. Under sedation, attempt was made to advance the sigmoidoscope and we were unable to pass the sigmoidoscope at this point. The patient was then put under general anesthetic by endotracheal tube and she was then prepped and draped in the usual fashion using Betadine scrub and solution. Once this was accomplished, operative area was infiltrated with local anesthetic. The colostomy was mobilized by dividing the retaining sutures and using gentle blunt and sharp dissection, the colostomy was mobilized from the subcutaneous tissue and fascia. Palpation of the abdominal cavity demonstrated multiple omental adhesions. As noted above, the fascia appeared to be quite tight, measured approximately 1 cm, was gently dilated digitally. Additional 1 cm incision was made in the rectus sheath at this level with partial vision of rectus muscle. This allowed for generous opening. The patient's abdominal cavity demonstrated multiple areas of rock-hard stool within the transverse colon. Initial attempts were made to remove these with ring forceps. However, this was unsuccessful. Using gentle digital dissection, the colon was partially disimpacted of stool. Gloves were changed and a Foley catheter was placed at the end of the bowel. It was inflated and 1200 cc of saline was then used to irrigate the colon. Approximately 4 cm proximal to the Foley, there was leakage of the irrigant indicating a tear on the wall of the colon. This was controlled with a right-angle clamp. There was no appreciable spill of stool. I elected to further mobilize the colostomy so that we may resect the colon just proximal to the area of the tear. After irrigation, the colon was mobilized between Kelly clamps and ties. It was divided between Allen clamps and the affected portion was passed off the field. Colostomy was then matured by using multiple sutures of 2-0 Vicryl. Two sutures of 0 silk were first placed to attach the colon to the peritoneum. The colostomy was then matured using multiple sutures of 2-0 Vicryl. At the completion of the procedure, the lumen was widely patent. There was no evidence of a fascial stricture. Appliance was applied and completion sigmoidoscopy actually documented widely patent lumen, no
evidence of mucosal injury and liquid stool within the colon. The patient tolerated the procedure well. The appliance was closed. She was brought back to recovery room in stable condition.

Edith Answered Tue 04th of January, 2011 10:59:39 AM

The provided documentation dictates that the patient has been carried to the operative room for revision of her colostomy (due to failed colostomy output-a complication of the earlier surgery). During the procedure, surgeon mobilizes the colostomy (performs colostomy revision) and notes a tear in the colon wall (which is actually causing complication in existing colostomy). To rectify the condition, surgeon then decides to remove the affected portion of colon and excises the colon portion containing tear. The colon is then anastomosed (connected) with the underlying peritoneum and sigmoidoscopy is then completed for procedural post assessment. CPT 44140 (Colectomy, partial; with anastomosis) can be used to report the performed service. Colostomy revision (44340-44346 series) is bundled in CPT 44140 as per CCI Edit and a modifier is not allowed. Hence, it cannot be separately reported with 44140). Sigmoidoscopy (CPT 45330) is performed only to facilitate colectomy procedure and to perform post-procedural assessment. Moreover, it’s bundled in CPT 44140 per CCI Edit and is not performed distinctly for a separate medical necessity during the course of the procedure. Hence, this should not be separately reported alongwith colectomy procedural code. Above mentioned findings (based on operative report) direct us to use CPT 44140, which can further be supported by ICD 569.89 (used for reporting colon tear), which provides the medical necessity for CPT 44140). Moreover, modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period) can also be appended with CPT 44140 if its performed under the global surgical/postoperative period of the initial service (performed earlier), {due to a complication of previous initial surgery} and by a physician of same group/specialty. Hope this helps!

Carol Posted Tue 04th of January, 2011 15:38:49 PM

that helps out alot thank you!! if its not too much would you be able to explain the 44625 code? sorry

SuperCoder Answered Sat 08th of January, 2011 20:09:28 PM

There are three codes which describe the revision of a colectomy.Code 44340 describes the release of superficial scar tissue, 44345- Revision of colostomy; complicated (reconstruction in-depth), 44346 Revision of colostomy; with repair of paracolostomy hernia (separate procedure)
Correct code selection is dependent upon the services performed during the surgical encounter.

According to the operative report the physician released the stricture. Also during the procedure, the physician “refreshed” the end of the colon by transacting the portion that had the tear. This was not a true resection since two ends of the colon were not joined (anatomized). Code 44340 includes transection of the distal stoma as well as revising the colostomy by pulling the end of the colon through the abdominal wall. Therefore, in this situation code 44340 describes the services performed.

The sigmoidoscopy is inclusive to the revision and therefore not separately billable.

Edith Answered Thu 13th of January, 2011 07:08:38 AM

Description of code: 44625

Surgeon resects and closes the stoma (enterostomy) of either small intestine or colon (other than colorectal) and the intestinal ends are reconnected (anastomosed) together through staples or sutures.

Description of 44340

Colostomy revision is performed through incision around stoma and the scar (granulation/fibrous connective tissue) is disconnected (released) from the adjacent tissues. The distal stoma is transected (cut across or divided transversely) and the colostomy is reestablished (while pulling additional colon through the abdominal wall). This code does not cover any kind of excision/resection of colon.

Description of 44140

This code covers excision of a segment of colon (with anastomosis). In this procedure the segment of colon is isolated and divided between clamps and the affected portion is passed off (resected/excised) from the remaining colon. When the resection is complete, the surgeon has the option of either immediately restoring the bowel, by stitching or stapling together both the cut ends (primary anastomosis), or creating a colostomy or reestablishing/revising the preexisting colostomy after bowel partial resection. As there is no code available for Colectomy, partial; without anastomosis, 44140 can still be used for partial colectomy, wherein the bowel ends are surgically not reconnected together after colon partial excision (i.e. after colon partial excision, remaining distal end of colon may be reapproximated to peritoneum through sutures). In such a typical scenario, there is an option of reporting 44140 with modifier 52 (Reduced Services)-as a true anastomosis is not performed. This procedure also includes colostomy revision and sigmoidoscopy services per coding guideline.

Hence, after a thorough analysis of the above mentioned codes details and the procedural documentation in operative report, you can decide about the most appropriate CPT code to report the rendered service.

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