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Please help code Ulcer resection and aneurysmectomy off/at AV fistula

DX: Right arm AV fistula with ulceration and aneurysm in the setting of end stage renal disease.

Operation performed:

1. Aneurysmectomy of the right upper extremity AV fistula aneurysm.
2. Ulcer resection of this ulceration of the skin in the right upper extremity.
3. Aneurysmorrhaphy and aneurysmectomy with ulcer resection.

Indications for procedure: t
This is a patient, who has right upper extremity AV fistula and he then has had aneurysmal disease dilatation in _____ segments as well as an ulceration of the skin that is at risk of rupturing.

Procedure:
The patient was appropriately consented and brought to the operating room, prepped and draped in sterile fashion. Right upper extremity was prepped in sterile field. Infusion of lidocaine anesthetic was infused around the larger of the 2 masses and an encompassing separation of the ulceration from the AV fistula took place. Sharp elliptical incision was made around the larger of the 2 masses _____ was made, carried around the proximal and distal portions of the AV fistula and the ulceration was resected, sent off to pathology. The same was done for the aneurysm. Aneurysm was encircled proximally and distally. There was control that was made and a subsequent aneurysmectomy took place with aneurysmorrhaphy using running 6-0 prolene suture as well as a endo-gia stapler _____ . After the case, there was a good thrill through the fistula and good hemostasis and the fistula was in good shape and much more _____ caliber and size postprocedure. the patient tolerated the procedure well. A running 3-0 nylon was used to close the suture.

Medical Billing and Coding Forum

Please help code Ulcer resection and aneurysmectomy off/at AV fistula

DX: Right arm AV fistula with ulceration and aneurysm in the setting of end stage renal disease.

Operation performed:

1. Aneurysmectomy of the right upper extremity AV fistula aneurysm.
2. Ulcer resection of this ulceration of the skin in the right upper extremity.
3. Aneurysmorrhaphy and aneurysmectomy with ulcer resection.

Indications for procedure
: t
This is a patient, who has right upper extremity AV fistula and he then has had aneurysmal disease dilatation in _____ segments as well as an ulceration of the skin that is at risk of rupturing.

Procedure:
The patient was appropriately consented and brought to the operating room, prepped and draped in sterile fashion. Right upper extremity was prepped in sterile field. Infusion of lidocaine anesthetic was infused around the larger of the 2 masses and an encompassing separation of the ulceration from the AV fistula took place. Sharp elliptical incision was made around the larger of the 2 masses _____ was made, carried around the proximal and distal portions of the AV fistula and the ulceration was resected, sent off to pathology. The same was done for the aneurysm. Aneurysm was encircled proximally and distally. There was control that was made and a subsequent aneurysmectomy took place with aneurysmorrhaphy using running 6-0 prolene suture as well as a endo-gia stapler _____ . After the case, there was a good thrill through the fistula and good hemostasis and the fistula was in good shape and much more _____ caliber and size postprocedure. the patient tolerated the procedure well. A running 3-0 nylon was used to close the suture.

Medical Billing and Coding Forum

Multi Provider repair of Enterovesicular Fistula

This is a concurrent case with general surgery and urology, any guidance will be much appreciated.
I have posted scrubbed note highlights. I have also added codes next to the listed procedures.
Thank you in advance for any guidance.

Will this also need modifiers for multiple surgeons??
Patient is male.

UROLOGY NOTE:

PREOPERATIVE DIAGNOSIS: Colovesical fistula. N32.1

POSTOPERATIVE DIAGNOSIS: Colovesical fistula.

PROCEDURES PERFORMED:
1. Cystourethroscopy with bilateral ureteral catheter placement (will be removed postoperatively) 52005-50
2. On table cystogram. 51600 (NCCI edits say it cannot be coded with 52005 – no unbundling allowed)
** imaging for cystogram 74430
3. Cystorrhaphy 51865
** with omental interposition. 49905????

GENERAL SURGERY NOTE:
PREOPERATIVE DIAGNOSIS: Enterovesicular fistula. N32.1

POSTOPERATIVE DIAGNOSIS: Enterovesicular fistula.

PROCEDURE:
1. Exploratory laparotomy. BUNDLES
2. Lysis of adhesions. APPEND -22 TO PRIMARY PX
3. Ileocecectomy. 44160
4. Ileocolic anastomosis. BUNDLES TO ILEOCECECTOMY
5. Urachal remnant/ peritoneal flap creation. 49905???

Urologist
— cystoscopy
— performed a cystogram
–Following his cystogram, we replaced the cystoscope and cauterized several small mucosal tears as a result of slightly overfilling his bladder
— placed ureteral catheters,

General surgeon
–They mobilized the bowel and remove the portion of small bowel
adherent to the posterior wall of the bladder.
–They had excellent exposure of the bladder and retracted the bowel cranially so we could fully visualize the fistula.

Urologist
–We mobilized the peritoneum on either side and covered this fistula with interrupted Vicryl sutures.
–We then mobilized the omentum with the base off of the right
gastroepiploic artery for interposition flap.
— we performed another cystogram using methylene blue and noted no extravasation of methylene blue.
** We then turned the rest of the case over to our general surgery colleagues who would later place the omental interposition graft following their bowel resection.

General surgeon
— urachal remnant that had been taken down from the umbilicus at the beginning of the case was then packed over this area of repair as an extra added layer and a omental pedicle flap was created by urology

— attention to creating the bowel anastomosis.
— bowel was isolated per our colorectal protocol and a stapled anastomosis was created

Medical Billing and Coding Forum

mucous fistula creation

Patient is a 11 day old patient that had a tunneled central line placement , av small bowel resection , Meckel’s Diverticulectomy, ileostomy, and a mucous fistula creation , so far I have

36558- catheter
77001-26
44120 -small bowel resection
44800- Meckel’s Diverticulectomy
Ileostomy and Mucous Fistula Creation ??????? , I am not sure of , can someone point me in the right direction ?

Thank you

Medical Billing and Coding Forum

Help coding excision elbow bursal cutaneous fistula

Hi Everyone,

This is my first time posting! I am in need of help with coding the excision of elbow bursal cutaneous fistula. The op note reads…

An elliptical incision was marked around the small bursal cutaneous tract and this was after the ellipse was marked out to excise this. Then,
10 mL of 1% lidocaine with epinephrine was infiltrated into the skin and subcutaneous tissues. At this point, full-thickness ellipse of skin was resected down to the olecranon bursa. Olecranon bursa showed some steroid white chalky deposits that were noted, some of these were excised as
well and a small portion of the bursa was also excised. The fistula tract appeared to come with the skin and this was excised as well. The bursal area was then thoroughly irrigated and closed using interrupted 3-0 nylon sutures and a sterile dressing was applied with a compression dressing.

I am at a loss on this one. Thanks for your help, Lisa

Medical Billing and Coding Forum