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In: Nursing

LOCATION: Inpatient, Hospital PATIENT: Simon Sulten ATTENDING PHYSICIAN: Gary Sanchez, MD SURGEON: Gary Sanchez, MD PREOPERATIVE...

LOCATION: Inpatient, Hospital

PATIENT: Simon Sulten

ATTENDING PHYSICIAN: Gary Sanchez, MD

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSES 1. Colostomy for obstructing colon cancer. 2. Cholelithiasis.

POSTOPERATIVE DIAGNOSES: Same as Preoperative.

PROCEDURES PERFORMED 1. Takedown colostomy with end-to-end colorectostomy. 2. Open cholecystectomy.

ANESTHESIA: General.

PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped sterilely. The previous midline was reopened with the #10 blade, and we excised the old scar. We carried our dissection through subcutaneous tissues using electrocautery. Midline fascia was divided sharply. We entered the peritoneal cavity and entered the midline fascia along the length of the incision. We took down numerous filmy adhesions and ran the small bowel from the terminal ileum to the ligament of Treitz, which appeared normal. First, we placed an Omni retractor and exposed the right upper quadrant. We identified the cystic duct and cystic artery and tied them off with 0 silk ties distally before transecting them. We then shelled the gallbladder from its fossa using electrocautery. We placed a pack up by the liver bed. We then identified the rectal stump and dissected this free. We then made an elliptical incision around the colostomy opening and carried our dissection down to fascia, freed up the stoma, and fired our TLC-75 stapler across the descending colon. We then sent the specimen to pathology. We mobilized the left colon along the avascular line of Toldt up and around the splenic flexure. Once we had adequate length we placed a Glassman clamp proximally on the rectum and distally on the descending colon. We then performed a two-layer, hand-sewn, end-to-end anastomosis with an outer layer of 3–0 silk Lembert and inner layer of running 3–0 Vicryl. There was a patent anastomosis, and we could easily milk contents through with no evidence of spilling. We then closed the fascia from the colostomy site with interrupted 0 Vicryl and running 0 PDS. We closed the skin with skin clips.

All sponge and needle counts were correct. The patient tolerated the procedure well and was taken to recovery in stable condition.

Abstracting & Coding Questions:

1. What was the approach?

2. What did the surgeon do with the existing colostomy?

3. What did the surgeon do with the intestinal opening left by removal of the colostomy?

4. What type of diagnosis code was reported for the resection of the colostomy?

5. What is a stoma?

6. What CPT code(s) would be reported for this case?

7. What ICD-10-CM code(s) would be reported for this case?

Expert Solution

1. what was the approach?

Ans: the surgeon chosen approach of surgery was open procedure

2. What did the surgeon do with the existing colostomy?

Ans : surgeon has performed colon anastomosis with and existing colostomy by end to end anastomosis for that surgeon has sent biopsy has obtained whether still its present cancer genic cells or not

3. What did the surgeon do with the intestinal opening left by removal of the colostomy?

Surgeon has left colon open for the passage fecal material’s

4. What type of diagnosis code was reported for the resection of the colostomy

Ans: Colon cancer -C18.9

5. Stoma

Ans: stoma is the artificial opening for colon

Ex; rectal stoma it allows the passage fecal materials by artificial method we need kept stoma bag that with attaching stoma site automatically fills bag when fecal drained from stoma

CPT codes

44145, 47562

ICD - C18.9, K56.69, K80.81

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