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Code This!

Scenario Week of March 16, 2012:
View Current Scenario

Assign the appropriate ICD-9-CM and CPT codes for the following scenario:

Preoperative diagnosis: Small bowel obstruction with perforated viscus.
Postoperative diagnosis:

  1. Small bowel obstruction with perforated viscus
  2. Ischemic small bowel

Procedure:

  1. Exploratory laparotomy
  2. Segmental small bowel resection
  3. Lysis of adhesions

Anesthesia: General
Specimens: Small bowel
IV fluid: 4 liters crystalloid, 3 units packed red blood cells, 500 cc Hespan
NG tube drainage: 800 cc

Procedure:
Patient presented with increasing abdominal pain. Initial films showed small bowel obstruction. Abdominal pain progressed in addition to some hypotension. Repeated abdominal films showed free intraperitoneal air. Emergent surgery was required. Patient was brought to the operating room and placed in the supine position. After administration of general endotracheal anesthesia, patient’s abdomen was shaved, prepped, and draped in the usual sterile fashion. A midline laparotomy incision was then made and carried down to the subcutaneous tissues using the Bovie electrocautery. The abdomen was carefully opened in the midline. The fascia and peritoneum were divided the length of the incision. Upon opening the abdomen, there was a return of a large amount of bloody peritoneal fluid with some particulate matter. Immediately visible was some obviously gangrenous small bowel. Once all the fluid had been suctioned from the abdomen, the small bowel was eviscerated. There were some omental adhesions from the patient’s previous surgery that were taken down with a combination of Bovie and blunt dissection.

Upon eviscerating the bowel, there was a long segment of small bowel which was gangrenous and this appeared to originate from an adhesive band in the right lower quadrant from patient’s previous appendectomy. This band was released. There was a significant amount of small bowel proximally that was viable and the very terminal ileum as well as the colon appeared normal. The proximal and distal lines of resection were identified and the bowel was divided in these areas using a GIA 75 stapler. The intervening mesentery to this ischemic and dead bowel was then taken down using clamps and combination of 2-0 silk as well as #0 Vicryl ties. Once this mesentery was completely taken down, the specimen was removed and set on the back table. This was later measured and found to be 150 cm. Further dissection was used to take down the remaining adhesions, identifying the patient’s upper abdominal anatomy. The stomach was visualized and appeared normal. NG tube was palpated within the stomach. The liver was visualized. There were no obvious abnormalities. The spleen also felt normal. The patient had previously undergone Whipple resection. There were some continued adhesions in the upper abdomen that were left intact. The small bowel was visualized going up to his biliary enteric anastomosis as well as his TJ anastomosis. Both of these areas appeared normal. The abdomen was copiously lavaged with approximately 6 liters of warm sterile saline and a large amount of particulate matter was removed at that time.

The small bowel was then reanastomosed in a side-to-side functional end-to-end fashion at the terminal ileum leaving the ileocecal valve intact. Measuring with an umbilical tape, there was approximately 200 cm of remaining small bowel that was viable. Once the anastomosis was completed, the mesenteric defect was closed using interrupted 3-0 silk sutures. The staple lines of the anastomosis were also imbricated using 3-0 silk sutures. At that time, it was elected to conclude the operation. The fascia was reapproximated in the midline using a running #0 PDS stitch starting inferiorly and superiorly and tied just above the umbilicus. The incision was then closed with staples. Sterile dressings were applied. The patient tolerated this reasonably well.


ANSWERS

ICD-9-CM Diagnosis Codes
560.81 Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)
557.0 Acute vascular insufficiency of intestine
569.83 Perforation of intestine

According to official ICD-9-CM guidelines, the principal diagnosis is defined as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” In this scenario, the adhesions caused an obstruction of the small bowel resulting in ischemia and necrosis of the small bowel, so the code for the adhesions with obstruction was selected as the primary diagnosis. Inclusion terms under code 557.0 lets coders know the code describes a number of conditions including necrosis and gangrene of intestine, both of which are documented in the operative report. The patient is also noted in the operative report to have a perforation of the bowel.

CPT Procedure Code
44120 Enterectomy, resection of small intestine; single resection and anastomosis

Rationale
CPT code 44120 describes the resection performed. A laparotomy would not also be reported in this scenario. Defined as a “separate procedure,” the laparotomy is an integral part of the total service, which is the resection of the small bowel, and does not warrant a separate identification. A code to report the lysis of adhesions in this situation would also not be reported separately. According to the CPT Assistant, January 2000 issue, it may be appropriate to also report code 44005 for the lysis of intestinal adhesions when “dense, extensive adhesions require significantly greater physician work and procedural complexity, it would be appropriate to report code 44005-59 in addition to the intestinal surgery procedure.” Although adhesions are documented in this scenario, the surgeon’s documentation fails to indicate that they are significant enough to warrant additional coding.

 

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