CPC Chapter 11- Digestive System Practical Review Flashcards
CASE 1
Preoperative Diagnosis: Right-sided colonic polyps.
Postoperative Diagnosis: Right-sided colonic polyps.
Procedure: Laparoscopic right hemicolectomy with ileocolic anastomosis.
Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine, modified-lithotomy position and Allen stirrups. Great care was taken to carefully pad and protect all areas of potential bodily injury. The abdomen was prepped and draped in the usual sterile manner.(Positioning and draping the patient is standard of care - not billable.)
Using a supra-umbilical vertical incision, a Hasson technique(Type of laparoscopic approach. The Hasson technique employs an open type of port insertion site for laparoscopic procedures.) was employed to carefully place a 10 mm cannula. Carbon dioxide pneumoperitoneum of 15 mmHg was achieved, after which a 30-degree telescope was carefully introduced. Under direct vision, two left-sided ports were placed: one in the left lower quadrant, one in the left upper quadrant, each lateral to the epigastric vessels through horizontal stab wounds.(Placement of the trocars for visualization into the abdominal cavity.) With a combination of head up, head down, and right side up, the entire right colon was mobilized from the duodenum, pancreas, and right ureter, using 10 mm diameter Babcock grasping forceps and 5 mm diameter harmonic scalpel.(The colon is freed away from it’s attachments to other structures. The Babcock grasper holds the colon in place while the harmonic scalpel cuts away the connections.)
After complete mobilization and copious irrigation and verification of meticulous hemostasis, the supraumbilical port was lengthened to 4 cm, through which an Alexis wound protector was placed. The entire right colon was withdrawn.(Pulled to outside the cavity through the extended incision.) High ligation of the ileocolic arcade and the right branch of the middle colic(The division of the colon.) were undertaken using 10 mm diameter LigaSure Atlas.(Device used to seal or divide the circulation to that portion of the bowel slated for removal.) The Atlas was used for the remaining mesentery. The bowel was circumferentially cleared of fat proximally and distally, and each end was divided with a GIA 100 mm stapler with a blue cartridge. The field was draped with blue towels, and the antimesenteric border of each staple line was excised along with the terminal ileum. A side-to-side, functional end-to-end anastomosis was fashioned between the remaining ileum and colon with a GIA 100 mm stapling device with a blue cartridge.(Reattachment of the two ends of the colon: ileocolostomy.) The staple line was verified for hemostasis, after which the afferent limb was secured to the efferent limb with 3-0 PDS II seromuscular Lembert-type sutures. After verification of anastomotic hemostasis, the apical enterotomy was also secured with a GIA 100 mm stapling device with a blue cartridge. The anastomosis was healthy, pink, widely patent, circumferentially intact, and easily returned into the peritoneal cavity.(The externalized colon is reinserted into the abdominal cavity after it is checked for hemostasis and perfusion.)
After copious irrigation and verification of meticulous hemostasis, the fascia was closed with interrupted No. 1 Vicryl plus figure-of-eight sutures. The subcutaneous layers were irrigated and meticulous hemostasis was verified. Port sites were closed in a similar manner. The skin was closed and covered by dry dressings,(After the trocars are removed, the stab sites are sutured closed.) and the patient was discharged to the recovery room in stable condition, without having suffered any apparent operative complications.
What are the CPT® and ICD-10-CM codes for this service?
44205
K63.5
CASE 2
Procedure: Uvulopalatopharyngoplasty. (The procedure is to repair the uvula and tonsils.)
Indication: A 63-year-old with obstructive sleep apnea. He is intolerant of CPAP.
Description of Procedure: I identified the patient and he was brought to the operating room. General endotracheal anesthesia was induced without complication. Tonsillar pillars and palate were injected with 0.25% Marcaine. The right tonsil was grasped with an Allis forceps and dissected from the tonsillar fossa(Right tonsillectomy. It’s not billable because it’s included in the primary procedure.) with a combination of blunt and cautery dissection. The posterior pillar remained intact as I proceeded to do similar mobilization of the left tonsil.(Left tonsillectomy. It’s not billable because it’s included in the primary procedure - cannot be unbundled.) I then made a mucosa incision across the base of the palate approximately 0.5 cm from the base of the uvula, connecting the anterior tonsillar incisions. The muscular portion of the uvula and edge of the soft palate was then opened. Posterior pillar was opened inferiorly on the right tonsil fossa, and extended through the palate to include the uvula, and then extended inferiorly on the left side. The uvula, edge of the soft palate, and both tonsils were removed in total. Hemostasis was achieved with electrocautery. The mucosal incision was then closed with interrupted Vicryl sutures. The oral cavity was irrigated with clindamycin solution.
The patient was awakened, extubated, and brought safely to the recovery room.
What are the CPT® and ICD-10-CM codes for this service?
42145
G47.33
CASE 3
Procedure: Upper gastrointestinal endoscopy.
Reason(s) for Examination: Gastroesophageal Reflux Disease (GERD).(This shows medical necessity for the procedure.)
Description of Procedure:
Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to upper GI endoscopy were explained. The patient agreed to proceed. No contraindications were noted on physical exam. Anesthesia was administered by the ICU staff. (See anesthesiologist report) Monitored anesthesia care (MAC) was administered by anesthesia team. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted through the mouth to the second part of the duodenum. The patient tolerated the procedure well. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols.
Findings: The esophagus was examined and no abnormalities were seen. The gastroesophageal junction (upper level of gastric folds) was located 40cm from the incisors. The stomach was examined and no abnormalities were seen. The small bowel was examined and no abnormalities were seen.(An upper gastrointestinal endoscopy to the duodenum was performed.)
What are the CPT® and ICD-10-CM codes for this service?
43235
K21.9
CASE 4
Procedure: Sigmoidoscopy
Extent of Examination: Proximal sigmoid colon.
Reason(s) for Examination: Proctitis.
Postoperative assessment: Proctitis.
Description of Procedure:
Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to sigmoidoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Patient was re-examined and no interval changes were noted from the preoperative history & physical. After being placed on the table, patient identification was verified prior to the procedure. Immediately prior to sedation for endoscopy the patient’s ASA classification was Class 2: Mild systemic disease. Monitored anesthesia care (MAC) was administered by the anesthesia team.(This is important for the anesthesiologist.) The quality of the prep was adequate. Prior to the exam, a digital exam was performed and it was unremarkable.
The procedure was performed with the patient in the left lateral decubitus position. The sigmoidscope was inserted to the proximal sigmoid colon.(This is pertinent as the correct code is selected by the level of exam in the colon.) In the rectum, a retroflex was performed. The withdrawal time from the proximal sigmoid colon was 8 minutes. The patient tolerated the procedure well.
There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. IV moderate sedation was administered under direct supervision of the physician. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols.
Findings: In the rectum, mild segmental inflammation with erythema(These are the symptoms of proctitis; only use symptoms in the absence of a definitive diagnosis.) was seen. There was no mucosal bleeding.
What are the CPT® and ICD-10-CM codes for this service?
45330
K62.89
CASE 5
Preoperative Diagnosis: History of rectal carcinoma.
Postoperative Diagnosis: History of rectal carcinoma.
Procedure Performed: Closure of loop ileostomy with small bowel resection and enteroenterostomy with intraoperative flexible sigmoidoscopy.
Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine modified lithotomy position in Allen stirrups.(Lying on back with legs in stirrups.) Great care was taken to pad and protect all areas of potential bodily injury. Digital rectal examination revealed a widely patent circumferentially intact pouch anal anastomosis within 1 cm of the dentate line. Flexible sigmoidoscopy was performed revealing healthy pink mucosa. The abdomen was prepped and draped in the usual sterile manner, and a parastomal incision(Cutting around the ostomy opening to release it from the abdominal wall and surrounding area.) was made and carried down sharply into the peritoneal cavity. Meticulous hemostasis was obtained with electrocautery. A 360 degree subfascial mobilization was undertaken until approximately 40 cm of each the afferent and efferent limb reached above the skin in a tension-free manner. Betadine was insufflated down each limb to verify that no enterotomies or seromyotomies were made.(Verification that the colon is without injury or puncture from the dissection.) The mesentery was scored and vessels were divided with a 10 mm LigaSure Impact. The bowel was circumferentially cleared of fat proximally and distally, and each end was divided with a GIA 100 mm stapling device with blue cartridge. The field was protected with blue towels and the antimesenteric border of each staple line was excised. A side-to-side functional end- to-end anastomosis was fashioned with a GIA 100 mm stapling device.(Reattachment of the two ends of the colon in a side-by-side fashion.) The staple line was reinforced for hemostasis with 3-0 PDS 2 suture where necessary and the afferent limb was secured to the efferent limb with 3-0 PDS 2 seromuscular Lembert type sutures. After verification of the meticulous hemostasis, the apical enterotomy was secured with a GIA 100 mm stapling device. The anastomosis was healthy pink and widely patent and circumferentially intact and easily returned into the peritoneal cavity, after copious irrigation and verification of meticulous hemostasis.
What are the CPT® and ICD-10-CM codes for this service?
44625
Z43.2, Z85.048
CASE 6
Preoperative Diagnosis: Morbid obesity. BMI 40.
Postoperative Diagnosis: Morbid obesity. BMI 40.
Procedure Performed: Laparoscopic sleeve gastrectomy. Intraoperative esophagogastroduodenoscopy.
Intraoperative endoscopy
Anesthesia: General endotracheal anesthesia.
Operative Procedure: The patient was brought to the operating room and placed on the OR table in supine position. Once general endotracheal anesthesia was achieved and pre-op antibiotics were given, the abdomen was prepped and draped in the standard surgical fashion. Access to the abdominal cavity was through a 1 cm supraumbilical incision with an Optiview trocar. Co2 was insufflated to achieve an intraabdominal pressure of approximately 15 mmHg. Accessory trocars were placed in the subxiphoid, right, mid, and left upper quadrants of the abdomen, as well as in the right and left lower quadrants of the abdomen. All this was done under appropriate videoscopic observation.
The pyloric channel was then identified and approximately 4 cm proximal to it, the short gastric vessels of the greater curvature are taken down all the way up to the GE junction with the harmonic scalpel. A 38 french bougie is passed into the stomach into the pyloric channel and with the help of the linear cutter, the stomach is transected in a vertical fashion creating a gastric tube which is approximately 100 mm in diameter. The staple line is then over sewn with a running 2-0 Vicryl suture. Good hemostasis was achieved.
Then I performed intraoperative esophagogastroduodenoscopy. The scope was advanced through the oropharynx, and under direct vision it was taken down through the esophagus and into the sleeve. There was no evidence of leak, bleeding, or any other abnormalities. A patent sleeve was seen all the way down to the pylorus. The scope was then retrieved carefully.
A placement of a drain through the subhepatic space and extraction of the specimen through a right lower quadrant incision was done. All trocars were removed under appropriate videoscopic observation. There was no evidence of bleeding from any of the trocar sites. All the trocar sites were suture closed and injected with local anesthesia. The patient tolerated the procedure well. He was extubated on the table and transferred to the recovery room in stable condition. There were no complications.
What are the CPT® and ICD-10-CM codes for this service?
43775
E66.01, Z68.41
CASE 7
Preoperative Diagnosis: Cholelithiasis, chronic cholecystitis, and acute pancreatitis.
Postoperative Diagnosis: Cholelithiasis, chronic cholecystitis, and acute pancreatitis, pathology pending.
Procedure Performed: Laparoscopic cholecystectomy, with intra-operative fluoroscopic cholangiography.
Anesthesia: General anesthesia and 0.5% Marcaine (10 cc/s).
Estimated Blood Loss: minimal.
Drains: None.
Specimen: Gallbaldder.
Operative indications:
This is a 49-year-old female with the above diagnosis who presents for elective laparoscopy, cholecystectomy and intra-operative cholangiography.
Operative Procedure:
The patient was brought to the OR suite with PAS stocking in place. She was transferred to the operative table, given a general anesthetic, positioned supine on the table, and the operative field was sterilely prepped and draped.
A vertical incision was made in the base of the umbilicus and deepened through the fascia. Stay sutures of 0-Proline were placed, and the abdomen was entered under direct vision. A Hassan cannula was anchored in place with the stay sutures and the abdomen was insufflated to 15 mm Hg with CO2 gas.
A 10 mm, 30-degree scope was assembled, focused, weight-balanced, and placed into the abdomen. Cursory evaluation revealed no other obvious pathology with the exception of the gallbladder. Under direct vision, 3-5 mm ports were placed in the epigastrium, right upper quadrant, and right lower quadrant. The patient was placed in reverse Trendelenberg position, with the right side up.
The fundus of the gallbladder was grasped and retracted over the dome of the liver. Adhesions to the gallbladder were taken down with sharp and blunt dissection while carefully maintaining hemostasis with electrocauterery. The ampulla of the gallbladder was grasped with a second instrument and retracted downward and laterally, displaying the angle of Calot distracted from the portal structures, The cystic duct and artery were dissected circumferentially. A single clip was placed on the distal cystic duct and an opening created just proximal to it. The cholangiogram apparatus was introduced into the abdomen via the 5 mm RUQ port and the 5-French whistle-tip ureteral catheter was threaded into the common bile duct through the opening in the cystic duct. The cholangiogram was performed under fluoroscopy and was normal, demonstrating filling of the duct with defects and prompt flow into the duodenum. The cholangiogram apparatus was withdrawn from the abdomen, and the cystic duct was clipped twice proximally, and divided. The cystic artery was clipped once distally, twice proximally, and divided. The cystic duct and artery were dissected circumferentially, clipped once distally, twice proximally and divided. Care was taken not to encroach upon the common bile duct or portal structures.
The gallbladder was taken down from the liver using the hook-dissector and cautery carefully maintaining hemostasis during the process. The right upper quadrant was irrigated with saline and suctioned dry. Hemostasis was confirmed. There was no bile drainage from the gallbladder bed in the liver. A 5 mm, 30-degree scope was assembled, focused, white-balanced, and placed into the epigastric port. The gallbladder was removed under direct vision through the umbilical port. The other ports were removed under direct vision, and hemostasis was achieved.
The abdomen was de-insufflated. The fascia in the umbilical incision was closed with a figure of eight suture of 0 vicryl. The wounds were infiltrated with a total of 10 cc’s of 0.5% marcaine. The skin incisions were closed with subcuticular sutures of 4.0 vicryl. Steri-strips and sterile dressings were applied. After a correct sponge, instrument, and needle count, the patient was awakened, extubated, and taken to the recovery room in good condition.
What are the CPT® and ICD-10-CM codes for this service?
47563
K80.10, K85.90
CASE 8
Procedure: Colonoscopy
Extent of Examination: Terminal ileum.
Reason(s) for Examination: Anemia, Fe Deficiency.
Description of Procedure:
Informed consent was obtained and I explained about the benefits, risks, including the risk of perforation and alternatives to colonoscopy. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored anesthesia care (MAC) was administered by the anesthesia team. The bowel was prepared with GoLYTELY prep. The quality of the prep is based on the Ottawa bowel preparation quality scale. Total score: Right: 1 + Middle: 1 + Left: 1 + Fluid: 0 = 3/14. Prior to the exam, a digital exam was performed; hemorrhoids were noted.
The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted in the anus and advanced to the terminal ileum. The cecum was identified by the following: the ileocecal valve and the appendiceal orifice. In the rectum, a retroflex was performed. The patient tolerated the procedure well. There were no complications.
Findings: In the rectum, a few medium-size uncomplicated internal hemorrhoids were seen. The internal hemorrhoids were not bleeding. There was no evidence of inflammation, friability, granularity, or bleeding. Biopsy were taken. In the ascending colon and cecum there was mild granularity and red spots that were nonspecific and possibly due to air insufflation. No friability, ulcerations or bleeding. Biopsy taken. The remainder of the colon was normal. The terminal ileum was normal.
What are the CPT® and ICD-10-CM codes for this service?
45380
D50.9, K64.8
CASE 9
Procedure: Colonoscopy
Extent of Examination: Terminal ileum.
Reason(s) for Examination: Hx of rectal cancer s/p Low Anterior Resection (LAR) and colonic J pouch for closure of loop ileostomy.
Description of Procedure:
Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to colonoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored anesthesia care (MAC) was administered. The bowel was prepared with Fleets enemas. The quality of the prep was fair. Prior to the endoscopic exam, a digital rectal exam was performed and it was unremarkable. The procedure was performed with the patient in the left lateral decubitus position. The cecum was identified by the ileocecal valve. The withdrawal time from the cecum was 7 minutes. The patient tolerated the procedure well. There were no complications. The exam was limited by poor preparation.
Findings: At the splenic flexure, moderate inflammation with erythema, granularity, friability, and hypervascularity was seen. There was no mucosal bleeding. In the proximal descending colon, moderate segmental inflammation with erythema, granularity, friability, and hypervascularity. In the rectum an abnormality was noted.
Anastomosis is patent and normal. No evidence of polyp. Just proximal prior to anastomosis - significant diffuse colitis was noted.
What are the CPT® and ICD-10-CM codes for this service?
45378
K52.9, Z85.048
CASE 10
Preoperative Diagnosis: Severe obesity. Hypertension. BMI 53.
Postoperative Diagnosis: Severe obesity. Hypertension. BMI 53.
Procedure Performed: Laparoscopic antecolic Roux-en-Y gastric bypass with 150 alimentary limb, and a 40 cm biliopancreatic limb.
Anesthesia: General endotracheal anesthesia.
Operative Procedure: The patient was brought to the operating room and placed on the OR table in supine position. Once endotracheal anesthesia was achieved and pre-op antibiotics were given, the abdomen was prepped and draped in the standard surgical fashion. Access to the abdominal cavity was through a 1 cm supraumbilical incision with an Optiview trocar. CO2 was insufflated to achieve an intraabdominal pressure of approximately 15 mmHg. Accessory trocars were placed in the subxiphoid, right, mid and left upper quadrants of the abdomen, as well as in the right and left lower quadrants of the abdomen. All of this was done under appropriate videoscopic observation.
The procedure begins with identification of the gastroesophageal junction and dissection of the angle of His. On the lesser curvature of the stomach, a window is dissected into the lesser sac. A linear stapler is passed, and the stomach is transected. Reinforcement of the staple line was done with a continuous absorbable seromuscular suture, creating a pouch approximately 50 cc in diameter. An Ewald tube is used to calibrate the pouch. At this point, the ligament of Treitz is identified and 40 cm from the ligament of Treitz, the small bowel was transected. The distal limb of the small bowel is then brought to the upper abdomen, and a side-to-side gastrojejunostomy between the pouch and the alimentary limb is performed with a linear stapler. The gastrojejunostomy site is then closed with a double layer of running 2-0 Vicryl sutures. The anastomosis was observed for leakage with air and Methylene blue. There was no evidence of leakage.
I then proceeded 150 cm distal from the gastrojejunostomy. A side-to-side jejunojejunostomy was created between the biliopancreatic limb and alimentary limb. This was performed using two applications of the linear stapler. The jejunojejunostomy site was closed with several applications of the linear stapler. Hemoclips were applied to the suture line for hemostasis. Good hemostasis was evident. A 19 French Blake drain was placed over the gastrojejunal anastomosis. All trocars were removed under appropriate videoscopic observation. There was no evidence of bleeding from any of the trocar sites. The trocar sites were suture closed and injected with local anesthesia. The patient tolerated the procedure well. She was extubated on the OR table and transferred to the recovery room in stable condition. There were no complications.
What are the CPT® and ICD-10-CM codes for this service?
43644
E66.01, I10, Z68.43
