Colostomy- PCS Coding
Question: Based on the dictated Operative report, do I need further specificity to code the colostomy?
Operative report:
Procedure Performed
1. Exploratory laparotomy
2. Abdominoperineal resection
Described in the body of the report:
The area on the sigmoid colon was transected with a GIA 100 stapler and at this point, dissection was carried out in the perineal area.
Once this was completed, a left mid quadrant colostomy was fashioned which was marked preoperatively by excising a disc of skin, deepening it down through the subcutaneous tissues, opening the fascia in a cruciate type fashion and then placing a Mayo scissors through the fibers of the rectus muscle and poking full-thickness through the abdominal wall. Once this was done, it was dilated 2 fingerbreadths. The bowel was brought through after some of the fat was removed to allow it to pass through, and left intact with an Allen clamp. The abdomen was copiously irrigated with saline solution. When hemostasis was deemed adequate, Seprafilm was inserted. The peritoneum and posterior sheath were closed with a running 2-0 Vicryl stitch, and then the anterior sheath was closed with interrupted #1 Dexon stitches after irrigation of the subcutaneous tissue. Once this was completed, the subcutaneous tissue was re-irrigated. Skin clips were applied, and then the colostomy was matured by excising the staple row, and suturing the full-thickness to the skin to the full-thickness of the bowel circumferentially with 3-0 chromic catgut stitches. It was completely viable and digitalized and completely patent.
Specimen: Sigmoid, rectum and anus
Thank you.
Mayra Luciano, BS, BSN, RN
Clinical Dcoumentation Improvement Specialist
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772
631 438 5268
mluciano@bmhmc.org
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Operative report:
Procedure Performed
1. Exploratory laparotomy
2. Abdominoperineal resection
Described in the body of the report:
The area on the sigmoid colon was transected with a GIA 100 stapler and at this point, dissection was carried out in the perineal area.
Once this was completed, a left mid quadrant colostomy was fashioned which was marked preoperatively by excising a disc of skin, deepening it down through the subcutaneous tissues, opening the fascia in a cruciate type fashion and then placing a Mayo scissors through the fibers of the rectus muscle and poking full-thickness through the abdominal wall. Once this was done, it was dilated 2 fingerbreadths. The bowel was brought through after some of the fat was removed to allow it to pass through, and left intact with an Allen clamp. The abdomen was copiously irrigated with saline solution. When hemostasis was deemed adequate, Seprafilm was inserted. The peritoneum and posterior sheath were closed with a running 2-0 Vicryl stitch, and then the anterior sheath was closed with interrupted #1 Dexon stitches after irrigation of the subcutaneous tissue. Once this was completed, the subcutaneous tissue was re-irrigated. Skin clips were applied, and then the colostomy was matured by excising the staple row, and suturing the full-thickness to the skin to the full-thickness of the bowel circumferentially with 3-0 chromic catgut stitches. It was completely viable and digitalized and completely patent.
Specimen: Sigmoid, rectum and anus
Thank you.
Mayra Luciano, BS, BSN, RN
Clinical Dcoumentation Improvement Specialist
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772
631 438 5268
mluciano@bmhmc.org
DISCLAIMER:
This e-mail and any files transmitted with it are confidential and are
intended solely for the use of the individual or entity to which they
are addressed. This communication may contain material protected by
the attorney-client privilege. If you are not the intended recipient
or the person responsible for delivering the e-mail to the intended
recipient, be advised that you have received this e-mail in error and
that any use, dissemination, forwarding, printing, or copying of this
e-mail is strictly prohibited. If you have received this e-mail in
error, please immediately notify the sender via return e-mail or call
Brookhaven Memorial Hospital Medical Center at (631) 654-7282.
Comments
sb
If so, I believe you can use sigmoid for the colostomy. Coding Clinic had info on this in 4th Qtr 2015. I have pasted the one regarding colostomy and APR below. A total of 4 codes are required.
Question:
The above patient also had colostomy creation at the same time that the lower anterior resection of the rectum was performed. Should the colostomy be coded?
Answer:
Yes, creation of the colostomy should be separately coded. In this case the sigmoid colon was bypassed to skin, and is appropriately coded to the root operation "Bypass." Assign the ICD-10-PCS code as follows:
0D1N0Z4
Bypass sigmoid colon to cutaneous, open approach
In ICD-10-PCS, the root operation "Bypass," is defined as altering the route of passage of the contents of a tubular body part. Bypass is coded when the objective of the procedure is to reroute the contents of a tubular body part. The range of "Bypass" procedures includes normal routes such as those made in coronary artery bypass procedures, and abnormal routes such as those made in colostomy formation procedures.
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Abdominoperineal resection
Coding Clinic, Fourth Quarter ICD-10 2014 Pages: 40-41 Effective with discharges: December 31, 2014
Related Information
Question:
A 57-year-old male with low rectal cancer presents for abdominoperineal resection (APR) of the rectum with reconstruction to follow. A cylindrical APR was performed, along with excision of the sigmoid colon and resection of the anus. Should the excision of the sigmoid colon and resection of the anus be reported separately?
Answer:
Yes, the resections of the rectum and anus as well as the excision of the sigmoid colon are separately coded. To capture the entire surgery, all three codes are required. Assign the following ICD-10-PCS codes:
0DTP0ZZ
Resection of rectum, open approach
0DTQ0ZZ
Resection of anus, open approach
0DBN0ZZ
Excision of sigmoid colon, open approach
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
Thank you so much for your input!
Mayra Luciano, BS, BSN, RN
Clinical Dcoumentation Improvement Specialist
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772
631 438 5268
mluciano@bmhmc.org