ICD 10 procedure code hiatal hernia

Comments

• ssalinas

  September 2015 edited April 2016

  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

  September 2015 edited April 2016

  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

  September 2015 edited April 2016

  "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

  September 2015 edited April 2016

  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