ICD 10 procedure code hiatal hernia

tiffany.andras

? Can anyone share, just making sure I have this coded appropriate ?
Example :
NAME OF PROCEDURE:
1. Open Roux-en-Y gastric bypass.
2. Hiatal hernia repair

Here is part of the body of the procedure :
gastrojejunostomy was marked with a stitch. Measuring distally another 150 cm
were measured and the jejunal jejunostomy anastomosis was performed in the
usual anatomic fashion in a side to side functional end to end anastomosis
using multiple tan staple loads and the mesenteric defect was closed with a
running 2-0 nylon.

0D160ZA BYPASS STOMACH TO JEJUNUM,OPEN APPROACH
OBQSOZZ REPAIR LEFT DIAGPHRAGM, OPEN APPROACH
OBQROZZ REPAIR RIGHT DIAPHRAGM, OPEN APPROACH

My concern is the hiatal hernia procedure?

Thanks any advice would be much appreciated.

Tiffany Andras LPN CCS CCDS
Thibodaux Regional Medical Center

ssalinas

I am no expert on I-10 but I don't think you have enough info to code the hiatal hernia repair. I don't see any description of the repair or procedure.

Anyone else?

Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org

tiffany.andras

SORRY here is the procedure in detail


PROCEDURE IN DETAIL: The patient was brought to the operating room, placed in
the supine position after already having received preop IV antibiotics and
preoperative administration of Lovenox, placed on activation of SCD's and TED
hoses. She underwent general anesthesia with good result. A sterile Foley
catheter was then placed. At this point, the patient's abdomen was then
prepped and draped in the usual sterile fashion. Upper midline incision was
made in the usual anatomic fashion. The fascia was divided and the Thompson
retractor was placed with appropriate retraction. Ligament of Treitz
identified and 150 cm was measured out and two 60 mm tan staple loads used to
divide the small bowel. The distal end which will become the new
gastrojejunostomy was marked with a stitch. Measuring distally another 150 cm
were measured and the jejunal jejunostomy anastomosis was performed in the
usual anatomic fashion in a side to side functional end to end anastomosis
using multiple tan staple loads and the mesenteric defect was closed with a
running 2-0 nylon. Once completed a vascular portion of the transverse
mesocolon was noted and this was dissected bluntly until a window was made
just below the gastroepiploic arterial arcade and the suture was then used to
pass the small bowel up to this area without difficulty. Using blunt
dissection a window was made on the lesser curve of the appropriate sized
pouch and a Penrose placed around this. Once all the appropriate vessels were
identified and preserved multiple Covidien tri staple 60 mm purple loads were
utilized to form the pouch. At this point anesthesia passed a OrVil into the
stomach and electrocautery was used to make a small defect with passing of the
accompanying tube and the OrVil was then placed without any difficulty. The
small bowel was then divided with electrocautery and the 25 mm EEA stapler was
introduced and brought out and the gastrojejunostomy anastomosis performed in
the usual anatomic fashion with no undue tension. Once completed, the EEA
stapler was removed and the defect in the small bowel was closed with a 60 mm
Covidien tri staple tan load. Once completed the colon was tacked down to the
area the transverse mesocolon to ensure no migration. At this point, the
Peterson defect was also closed with a running 2-0 Prolene. At this point,
using just finger pressure, the small bowel distal to the gastrojejunostomy
anastomosis was clamped between the fingers and the patient was placed in a
supine position. Upper abdomen was filled with saline and an oral esophageal
tube was placed by anesthesia and air was insufflated at 4 liters per minute
allowing distention of the gastrojejunostomy anastomosis under normal saline.
There was no evidence of bubbling. At this point, the air was aspirated by
anesthesia and all the air was aspirated from the upper abdomen. At this
point, because of the patient's size and inability to appropriately visualize
the CAT scan as needed, a 19-French Blake drain was placed through a separate
stab incision in the left upper quadrant and directed near the
gastrojejunostomy anastomosis. At this point, lap count, needle count and
sponge count were correct. All retractors were removed. The fascia was
closed with 0 looped PDS from above and below meeting in the midline. At this
point, gloves and gowns were changed and the subcutaneous layer was copiously
irrigated until clear. The skin was approximated with skin staples and
Aquacel AG dressing was placed over this and a drain dressing was placed over
the drain. At this point, lap count, needle count and sponge count were
correct again. At this point, the procedure was terminated. Patient was
awakened, extubated, taken to the recovery room, stable.

Thanks Tiffany

ssalinas

"At this point, the Peterson defect was also closed with a running 2-0 Prolene."

I guess this is the hernia repair? The Peterson defect following Roux-en-Y can result in a hernia. I am not sure a hernia actually existed during this surgery. It seems more like it a prophylactic suture of the defect that to avoid a hernia later.

I would not code any hernia repair without more info from surgeon. Even if you decide to code the hiatal hernia repair, laterality info is required.

Anyone else???

Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org

tiffany.andras

I spoke to general surgeons today and they have never classified a hiatal hernia as left/right they both suggested it as midline which defaulted to the bilateral? I agree with you about the procedure note also that it is still not clear enough. Hoping to bet a better response from the MD in the am.

Thanks for your help
Tiffany