What would you code ?
Need some help this is the surgical procedure that was carried out:
Procedure:
Robotic-assisted laparoscopic left colectomy with mobilization of the splenic flexure with conversion to an open procedure to complete the colorectal anastomosis.
Umbilical hernia repair which was accomplished with closure of the midline laparotomy incision
This is the findings noted by the MD in the operative report :
The lesion was noted to be at the splenic flexure by the tattooing. Complete splenic flexure mobilization was performed robotically however the middle colic mesentery was short and the transverse colon could not reach the rectosigmoid junction for anastomosis with the EEA stapler. An open operation was then required for further mobilization of the colon and division of the middle colic vessels to swing the transverse colon to the rectosigmoid junction for anastomosis.
Do I could the lap or not ? The coder and I do not agree.
Tiffany Andras LPN CCS CCDS
Clinical Documentatoin Improvement
Thibodaux Regional Medical Center
602 North Acadia Road
Thibodaux, La. 70301
985-493-4593
Procedure:
Robotic-assisted laparoscopic left colectomy with mobilization of the splenic flexure with conversion to an open procedure to complete the colorectal anastomosis.
Umbilical hernia repair which was accomplished with closure of the midline laparotomy incision
This is the findings noted by the MD in the operative report :
The lesion was noted to be at the splenic flexure by the tattooing. Complete splenic flexure mobilization was performed robotically however the middle colic mesentery was short and the transverse colon could not reach the rectosigmoid junction for anastomosis with the EEA stapler. An open operation was then required for further mobilization of the colon and division of the middle colic vessels to swing the transverse colon to the rectosigmoid junction for anastomosis.
Do I could the lap or not ? The coder and I do not agree.
Tiffany Andras LPN CCS CCDS
Clinical Documentatoin Improvement
Thibodaux Regional Medical Center
602 North Acadia Road
Thibodaux, La. 70301
985-493-4593
Comments
However, if a planned endo- case turns to an unplanned open, only the open is coded. There are some exceptional caveats, but I believe this is the general approach. Also, there are V Codes to document the endo- portion. Others?
With Best Regards,
Robert Billerbeck, MD CPC
Meditco LLC
You would use a Dx. code of V64.4X (Surgical procedure converted to open) and then only code the open procedure not both.
C.Clinic 2003 speaks to the V64.4X code usage. Check out the C. Clinic 1st Qrtr. 2011. Laparoscopically -assisted hemicolectomy which seems similar to your example. Hope this helps!
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com