Clinical Documentation: Connecting the Dots | Join Webinar & Earn 1 AAPC® CEURegister Now >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Pouch excision requested documentation

Stephanie Posted Mon 17th of October, 2011 20:32:39 PM

Regarding my question of pouch excision. The opertive report reads preopertive dx: Lt tuboovarian abscess pouch, vaginal fistula, history of recurrent pouchitis, history of perianal abcess with drainage. Postoperative dx: same as above: Operation: Exploratory laparotomy, extensive lysis of adhesions, small bowel resection, excision of ileoanal pouch, left salpingo-oophorectomy. Op note itself says: There were multiple loops of small bowel stuck to the pouch itself. There was an area of stricturing. We had to release this & finally we began mobilizing the pouch itself.The mesentery was on the posterior side.We were able to get behind the mesentery and very bluntly with the use of Bovie cautery to mobilize this posteriorly and then anteriorly & laterally, very careful after identifing both ureters since everything was fairly inflamed in the area. After being able to do this, we then were able to bring the pouch up and excise the specimen.

Sorry for the long op note description. I sent a request for help last we and you requested notes.

Thank you so much.

SuperCoder Answered Tue 18th of October, 2011 09:02:01 AM

Relating your earlier question to this op note, I can say that you wanted code for "excision of ileoanal pouch".
Along with ileostomy, the code will be 45136.
Along with other CPT codes, if the lysis of adhesions is extensive, you can use modifier 22 with the documentation of extra time taken than normal.

Related Topics