rectal prolapse procedure code
Hi All,
We have a patient that had a large rectal-sigmoid prolapse that was resected. The coder & I are unsure what procedure code should be assigned. I chose the 48.49 (other pull through resection of the rectum) code while she chose the 48.59 (other abdominoperineal resection of the rectum) code. I don't think that is appropriate since the surgeon did not use an abdominal approach at all. When reading the op note, to me it sounds as if he basically excised the colon that was external & anastomosed the end to the perineum? I would like to see what your thoughts are on code assignment. I have to say I have never really seen a procedure like this done here.
nursing home patient who has had problems with constipation and intermittent reducible
rectal prolapse for apparently several years as far back as at least 2008.
The nursing home where she stayed was unable to reduce her rectal prolapse
last night and brought her into the Emergency Room. The
prolapsed rectum was pink and viable and extended out at least 20 to 30 cm
and was significantly distended and unable to be reduced.
I had a long discussion with the patient as well as her son and daughter. I went over various alternatives
with them which include an open sigmoid resection, transperineal
rectosigmoid resection or leaving this alone
The patient was placed in the supine position with
legs elevated in stirrups. The perineum was then prepped and draped in
normal sterile fashion. The mucosa of the rectal prolapse was incised
circumferentially with cautery. Hemostasis was maintained with the
cautery. There appeared to be a herniation of omentum as well as sigmoid
colon into the prolapsed rectum which was then able to be reduced. The
sigmoid colon was able to be carefully brought out until it could no
longer easily be advanced but no significant tension would be on an anastomosis.
The mesentery of this sigmoid colon was tied off between 3-0 Vicryl ties.
The sigmoid colon was then transected grasping onto the edges of the
sigmoid colon. The specimen was then sent to Pathology. There were noted
to be numerous areas of diverticulosis but otherwise appeared unremarkable
in the sigmoid colon. A perineal to colon anastomosis was made with
interrupted 3-0 Vicryl sutures. After suturing the omentum to the lateral
pelvic side walls at both left and right sides to help hopefully prevent
any recurrence. The anastomosis appeared widely patent and free of any
ischemia. The perineum was then packed with Lidocaine Cream soaked gauze.
Thanks,
Laura
Laura Jansen, RN, Clinical Documentation Specialist
laura.jansen@hshs.org
Respect - Care - Competence - Joy
LEGAL DISCLAIMER: This message and all attachments may be confidential or protected by privilege. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in or attached to this message is strictly prohibited. Please notify the sender of the delivery error by replying to this message, and then delete it from your system. Thank you.
We have a patient that had a large rectal-sigmoid prolapse that was resected. The coder & I are unsure what procedure code should be assigned. I chose the 48.49 (other pull through resection of the rectum) code while she chose the 48.59 (other abdominoperineal resection of the rectum) code. I don't think that is appropriate since the surgeon did not use an abdominal approach at all. When reading the op note, to me it sounds as if he basically excised the colon that was external & anastomosed the end to the perineum? I would like to see what your thoughts are on code assignment. I have to say I have never really seen a procedure like this done here.
nursing home patient who has had problems with constipation and intermittent reducible
rectal prolapse for apparently several years as far back as at least 2008.
The nursing home where she stayed was unable to reduce her rectal prolapse
last night and brought her into the Emergency Room. The
prolapsed rectum was pink and viable and extended out at least 20 to 30 cm
and was significantly distended and unable to be reduced.
I had a long discussion with the patient as well as her son and daughter. I went over various alternatives
with them which include an open sigmoid resection, transperineal
rectosigmoid resection or leaving this alone
The patient was placed in the supine position with
legs elevated in stirrups. The perineum was then prepped and draped in
normal sterile fashion. The mucosa of the rectal prolapse was incised
circumferentially with cautery. Hemostasis was maintained with the
cautery. There appeared to be a herniation of omentum as well as sigmoid
colon into the prolapsed rectum which was then able to be reduced. The
sigmoid colon was able to be carefully brought out until it could no
longer easily be advanced but no significant tension would be on an anastomosis.
The mesentery of this sigmoid colon was tied off between 3-0 Vicryl ties.
The sigmoid colon was then transected grasping onto the edges of the
sigmoid colon. The specimen was then sent to Pathology. There were noted
to be numerous areas of diverticulosis but otherwise appeared unremarkable
in the sigmoid colon. A perineal to colon anastomosis was made with
interrupted 3-0 Vicryl sutures. After suturing the omentum to the lateral
pelvic side walls at both left and right sides to help hopefully prevent
any recurrence. The anastomosis appeared widely patent and free of any
ischemia. The perineum was then packed with Lidocaine Cream soaked gauze.
Thanks,
Laura
Laura Jansen, RN, Clinical Documentation Specialist
laura.jansen@hshs.org
Respect - Care - Competence - Joy
LEGAL DISCLAIMER: This message and all attachments may be confidential or protected by privilege. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in or attached to this message is strictly prohibited. Please notify the sender of the delivery error by replying to this message, and then delete it from your system. Thank you.