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