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Open modified Graham patch repair of duodenal perforation

Angel Posted Thu 14th of March, 2019 17:04:47 PM
Hello, my provider performed a diagnostic laparoscopy and decided to convert to an open procedure. A midline epigastric incision was made with a # 10 scapel. The soft tissues were divided with monopolar electrosurgery. I performed EGD to confirm that there was a single perforation and localize it. This was identified on the superior posterior aspect of the duodenal bulb just beyond the pylorus. A biopsy was performed of the ulcer and sent for histology. The defect was closed with running 3-0 PDS suture. The repair was then patched in a modified Graham patch repair method with a piece of omentum using 2-0 silk suture. Next the hiatal hernia was repaired with interrupted #0 Ethibond sutures with a bougie in place. The cardia of the stomach was pexied to the diaphragm with 2-0 silk suture. Next a #19 JP drain was placed an secured to the skin with 2-0 Nylon sutures. It was originally coded as 43840, 49905, 43332-59 and denied. Should this have been coded as 44602, 44905 and 43336-51,59? I believe the lap is included in the open procedure since it was converted after he started the procedure.
SuperCoder Answered Fri 15th of March, 2019 05:05:50 AM

Hi Angel,


If the location of the perforation is stomach, then CPT code 43840 would be the appropriate code but if the location of perforated ulcer is duodenum, then appropriate CPT code would be 44602. Verify the histology report to identify the exact area and choose the appropriate CPT code from the provided codes as per the location.


Also, choose the appropriate code for hernia repair as per the marked incision. Choose the appropriate CPT code as per approach:

  • CPT code 43332 - Laparotomy approach 
  • CPT code 43334 - Thoracotomy approach
  • CPT code 43336 - Thoracoabdominal approach


Code 49905 for intra-abdominal omental flap for hiatal hernia report is correct.


Also, per NCCI coding edits, when a laparoscopic procedure is converted into an open procedure, laparoscopic procedure is not coded separately. You will code only for the open procedures.



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