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E. maria Posted 7 Year(s) ago

Patient had undergone a right colectomy CPT 44160, several days later she was taken back to surgery for exploratory laparotomy with drainage of intra-abdominal abscess, lysis of adhesions, and resection of previous ileocolonic anastomosis with ileostomy. Can I use CPT code 44143? I find CPT code 44144, however, pt did not have the creation of the mucofistula.
Any help is appreciated.

Thank you

Maria Nunez

SuperCoder Posted 7 Year(s) ago

Code 44143 is the right code for the discussed scenario. Also check the global period for previously operated procedure (44160 - global period is 90 days). If 44143 fall under global period of 44160, use modifier 58.

Alan Posted 7 Year(s) ago

No, you cannot use 44143. That code is for main surgery being "Colectomy". But as far as the question goes, the F/U Op. is about exp. lap, abscess drainage, adhesiolysis and resection of previous previous ileocolonic anastomosis with ileostomy. So there is no colectomy done as such on the later date. Coding will depend upon detailed documentation.

Two more points: 1) If the surgery done on the later date falls within the global days of the initial Px (44160), add modifier 78 (and not mod 58) with the later day's Px codes. The conditions and Px on the later day does not look like anything anticipated or staged Px.

Alan Posted 7 Year(s) ago

This is more like an unplanned return to OR within a few days of 1st operation. So appending mod. 58 would not be correct here.

If you could provide further details on what exactly was done on the later date, that would be pretty helpful for answering this query. So far, I have identified: 1) Exp. lap; 2) Intra-abdominal abscess drainage; 3) Adhesiolysis; 4) Resection of previous previous ileocolonic anastomosis with ileostomy. Coding 44625 would be more appropriate.

Were there anything else that's done?

E. maria Posted 7 Year(s) ago

This is the op note:
Intraoperative findings: Multiple dense adhesions from previous surgery, right lower quadrant abscess, small disruption of anterior wall of previous ileocolonic anastomosis.

The patient was taken to the operating room, placed in supine position. Generel endotracheal anesthesia as induced. The patient's abdomen wa prepped in usual sterile manner. The previous longitudinal midline incision was opened. Upon entering the abdominal cavity, the omentum was noted to be densely adherent to the adbominal wall. This was carefully dissected away using sharp dissection and electrocautery. After careful dissection, access of the abdomen was initially gained to the right lower quadrant. The omentum was able to be reflected superiorly and right lower quadrant entered. The abscess cavity was entered and evacuated air, anaerobic cultures were obtained. Dissection was slowly carried toward the right mid abdomina anastomosis. There was noted to be a small disruption of the anterior wall of anastomosis. In order to adequately isolate the anastomosis, extensive lysis of adhesions was undertaken. In excess of 90 minutes was spent in lysing adhesions of the transverse colon, and multiple loops of small bowel. After careful tedious dissection, the anastomosis in the transverse colon, terminal ileum were isolated. The colon was divided several cm distal to the anastomosis using the GIA stapling device. The Ileum was then divided proximal to the anastomosis using the GIA stapling device. The mesentery to the resected portion of colon and small bowel was divided using Kelly claims and 2-0 VIcryl free ties. The specime was amputed and removed from the surgical field. Further lysis of adhesions was undertaken to gain adequate lenght on the terminal into the liver onto the abdominal wall as in the ileostomy. The abdomen was then carefully inspected to ensure adequate hemostasis and copiuouly irrigated with several liters of sterile saline. A 19-mm Blake drain was placed in the right pericolic gutter, brought out through a stab wound incision in the right upper quadrant. A circular stomal incision was made in the right mid abdomen and the ileum was delivered onto the abdominal wall in the tension-free manner. The midline fascia was closed using looped 0 PDS running suture. The fascial closure was reinforced using #1 Prolene retention sutures. The skin was loosely reapproximated using 2-0 Prolene interrupted sutures. Open portions of the wound were packed with Kerlix fluff wet-to-dry dressings. The retention sutures were tied over Red Rubber Robinson bolsters. The staple line from the ileum was resected and the ileostomy was matured using 3-0 Vicryl simple interrupted sutures.

Thank you

Alan Posted 7 Year(s) ago

Thanks, Maria, for providing the OP notes. From this, it's now evident that the doctor -- 1) freed intestinal adhesions from intestine, site of previous ileo-colonic anastomosis and adjacent bdominal wall ; 2) drained the abdominal abscess; 3) resected the ileo-colonic anastomosis portion ; 4) created a new ileostomy. The appropriated code would be 44144 with modifier 52.

Reason: 1) You cannot code 49002 since laparotomy is included within the overall procedure.
2) cannot code 44005 since that's bundled totally (cannot even overcome with mod. 59, as per CCI) within the much major Px partial colectomy, take-down previous anastomosis.
3) Here the part of colon that was previously operated for creation of ileocolonic anastomosis was resected, the section excised, then ileostomy was done using part of ileum ("...A circular stomal incision was made in the right mid abdomen and the ileum was delivered onto the abdominal wall in the tension-free manner..."). But there was no mucofistula creation. So the code should be 44144 with mod. 52.

Remember: There was no endcolostomy done, and no anastomosis, too. So coding 44143 or 44625 would not be correct. Also, though the OP notes mention about spending 90 min. for lysis of adhesion, it does not specify whether the doctor spent more than half of the total surgery time in doing that. Until and unless that is mentioned, insurances usually do not pay for extra work done (by appending mod. 22). Anyways, here you cannot code 44005 at all, due to CCI edits, so claiming extra payment for adhesion lysis is out of question.

Alan Posted 7 Year(s) ago

Also, do not forget to append mod. 78 depending upon the global days of previous code 44160, if the later surgery was performed within 90 days from the first Op. So the eventual coding could be 44144 - 52 , 78.

SuperCoder Posted 7 Year(s) ago

Hi Maria.

I asked for help on your case from general surgery coding expert, Marcella Bucknam, who is the consulting editor for General Surgery Coding Alert, because I was unsure of the exact answer. Using modifier 52 just doesn't seem correct given all the hours/work the physician spent (should the pay really be reduced?). Here is what Marcella had to say:

"I actually think this should be coded with an unlisted. It would be a disservice to this physician to reduce his reimbursement as he clearly spent hours performing this very complex procedure. Unfortunately, I’m unable to figure out exactly what this sentence means “Further lysis of adhesions was undertaken to gain adequate length on the terminal into the liver onto the abdominal wall as in the ileostomy.” Because of that, I’m unsure that there is not a code or codes that would be a better fit.

If I was the coder I’d ask the surgeon exactly what that sentence means and find out if there was some anastomosis and an ileostomy or if there was more of a Hartman procedure, etc. If it is (as it appears) that the previous anastomosis was simply cut out and an ileostomy was created and the distal segment was neither closed nor anastomosed nor a mucus fistula created, then I would use the unlisted and for pricing I would compare to 44144 with a modifier 22 for all of the extra hours dealing with the abscess and adhesions. I cannot tell about modifier 78 as I don’t know when the previous surgery was performed (it usually takes a while for dense adhesions to grow) and whether there is a global period or what the previous surgery was for.

I hope that helps. Sorry it’s not a really definitive answer.

Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC
Manager of Compliance Education"

Marcella's comments were based on the op note you provided. From your original question it appears 78 would apply because you reference "a few days later."

I hope this helps you.

Leesa A. Israel, CPC, CUC, CMBS
Executive Editor, The Coding Institute

Posted by E. maria, 7 Year(s). There are 8 posts. The latest reply is from SuperCoder.

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