Question

PREOPERATIVE DIAGNOSIS: Nonhealing duodenal ulcer.

POSTOPERATIVE DIAGNOSIS: Nonhealing duodenal ulcer.

PROCEDURES PERFORMED:
1. Exploratory laparotomy. 2. Partial gastrectomy (antrectomy). 3. Truncal vagotomy. 4. Gastrojejunostomy. 5. Cholecystectomy with intraoperative cholangiogram.

INDICATION: The patient is a 60-year-old female who presented with a nonhealing gastric ulcer. She has had symptoms for about a year. She complains of epigastric pain. Medical therapy with Prilosec failed, as did therapy for H. pylori. Biopsy of the ulcer has been done, and it was benign. The patient had a negative workup for gastrinoma. Calcium level was also normal. The patient now presents for exploratory laparotomy and partial gastrectomy. The risks and benefits were discussed with the patient in detail. She understood and agreed to proceed.

PROCEDURE: The patient was brought to the operating room. Her abdomen was prepped and draped in a sterile fashion. A midline umbilical incision was made. The peritoneal cavity was entered. Initial inspection of the peritoneal cavity showed normal liver, spleen, colon, and small bowel. There was an ulcer along the first portion of the duodenum just beyond the pylorus with some scarring. There was also an ulcer in the posterior part of the duodenal bulb, which was penetrating to the pancreas. We started dissection along the greater curvature of the stomach. Vessels were ligated with 2-0 silk ties. There was an enlarged lymph node along the greater curvature of the stomach, which was sent for frozen section. It proved to be a benign lymph node. This was the only enlarged node found during dissection. We then proceeded with truncal vagotomy. The anterior vagus and posterior vagus were identified. They were clipped proximally and distally, and a segment of each nerve was excised and sent for frozen section, and a segment of both vagus nerves was excised and confirmed by frozen section. An incision was made around the gastrohepatic ligament. The mesentery along the lesser curvature of the stomach was dissected. The vessels were ligated with 2-0 silk ties along the lesser curvature of the stomach. A Kocher maneuver was performed to aid mobilization. The pancreas was completely normal. No masses were found in the pancreas. There was penetration of the ulcer in the superior part of the head of the pancreas. Dissection was continued posterior to the stomach. The adhesions posterior to the stomach were taken down. The ulcer was in the posterior segment of the duodenal bulb just beyond the pylorus and it had penetrated the pancreas. All the posterior layer of the ulcer that was left adherent to the pancreas was shaved off. The stomach was divided with the GIA stapler so that the complete antrum would be in the specimen. The duodenum was divided between clamps. The stomach pylorus and first part of the duodenum were sent to pathology for examination. Then the duodenal stump was closed with running suture. Using 3-0 Lembert sutures, the posterior wall of the ulcer was incorporated for duodenal closure. The base of the duodenum was rolled over the ulcer, and it was all-incorporating to the duodenal closure. Our next step was to proceed with cholecystectomy. The gallbladder was separated from the liver, reflected, and taken down, and the gallbladder was divided from the liver with blunt dissection and cautery. The cystic artery was doubly ligated with silk. The cystic duct was identified. The cystic duct and gallbladder junction and gallbladder ducts were identified. Intraoperative cholangiogram was performed showing free flow of bile into the intrahepatic duct and into the duodenum. No leaks were seen. The cystic duct was doubly ligated, and the gallbladder was sent to pathology. The staple line in the proximal stomach was oversewn with 3-0 silk Lembert sutures. A retrocolic isoperistaltic Hofmeister-type gastrojejunostomy was performed on the remaining stomach and loop of jejunum. This was an isoperistaltic end-to-side two-layer anastomosis with 3-0 chromic and 3-0 silk. The stomach was secured to the transverse mesocolon with several interrupted silk sutures to prevent any herniation along the retrocolic space.

With the use of the CPT an ICD-10-CM manuals, code the scenario.

Answer 1

ICD -10 CM is International Classification of Disease ,tenth revision ,clinical modification. It is used by the physicians and other healthcare workers , Medicare and Medicaid companies to classify and code diseases, symptoms etc .

ICD code for nonhealing duodenal ulcer is K26.9

CPT code is current procedural terminology . It is a code used by health care workers and insurance companies to code medical ,surgical procedures .

CPT code for exploratory laparotomy is 49000

CPT code for truncal vagotomy is 43640

CPT code for partial gastrectomy is 43659

CPT code for gastrojejunostomy is 43820

CPT code for cholecystectomy with intraoperative cholangiogram is 47563