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Q&A Partial Gastrectomy sans gastrojejunostomy or duodenostomy with Gastrostomy Tube

DiCamille

Member
What's a coder to do? We've spoken to the surgeon to try to get a better picture, but he claims this is what he did - excised the portion damaged by the previous attempt.

PREOPERATIVE DIAGNOSIS
Gastric perforation status post attempted placement of a percutaneous gastrostomy tube.

POSTOPERATIVE DIAGNOSIS:
Gastric perforation status post attempted placement of a percutaneous gastrostomy tube.

OPERATIVE PROCEDURE
Exploratory laparotomy with partial gastrectomy with placement of a 20-French gastrostomy tube.

OPERATIVE FINDINGS
The patient had an attempted gastrostomy tube placement by the interventional radiologist At the time of this surgery, there was some moderate amount of clot in the belly and there was a full-thickness hole in the stomach along the greater curvature site of the antrum. This was probably about 5 mm in diameter.

DESCRIPTION OF PROCEDURE
Under general anesthesia, the patient was prepped and sterilely draped Upper abdominal midline incision was made, fascia was divided, peritoneal cavity entered. The stomach was identified and then delivered into the wound. The defect in the stomach was readily apparent We took LigaSure and divided omentum from the greater curvature so we could have greater access to the gastric wall. We then did a partial gastrectomy, we grasped the greater curvature of the stomach with a Babcock clamp; and then using a TA-60 stapler, we came across the stomach and excised a portion of the stomach measuring probably about 5 x 2 cm in length and diameter. We then chose a 20-French gastrostomy tube which we placed in the anterior wall of the stomach close to the greater curvature after placing a 3-0 silk pursestring suture. The seromuscular layer of the stomach was further inverted around the tube with additional 3-0 silk sutures. The stomach itself was tacked up to the anterior abdominal wall with 3-0 silk. The tube flushed well. The midline fascia was then reapproximated with running 0 loop PDS. Skin was closed with skin staples. The patient tolerated the procedure well, left the operating room in good condition.

We were initially led to 43631-52, 43632-52, and a stronger consideration of 43610-52. Feel like we're taking the same road every time we look at this report and left w/the feeling that we're not getting to the right place. Any thoughts would be greatly appreciated to get through this bit of quicksand. Thanks!
 

Laureen

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I agree with 43610 being the closer match in description and work involved. Why are you thinking modifier 52 would be needed?

If there was an unlisted procedure code of the stomach I'd say use that and submit documentation that it was very similar to 43610. I feel I could support this if questioned.


Findacode Research/Notes

43631 - Gastrectomy, partial, distal; with gastroduodenostomy

Plain English Description
A partial gastrectomy is performed to remove the lower (distal) portion of the stomach. An incision is made in the abdomen and the stomach exposed. The stomach is divided at the pylorus and mobilized to expose the left gastric artery. The vascular pedicle is clamped, the stomach contents evacuated, and the stomach decompressed. Branches of the left gastric artery are identified, divided, and suture ligated distal to the vascular clamp. The clamp is released and hemostasis verified. The proximal resection site is identified and marked with a suture. The distal point of the resection is identified and marked with noncrushing clamps. The stomach is divided and staples applied. The staple line is oversewn with sutures and hemostasis secured. The remaining stomach segment is aligned with the remaining segment of intestine and temporary stay sutures placed. The temporary sutures are replaced with running sutures and the stomach serosa approximated to the intestinal serosa. Report 43631 if the stomach is sutured (anastomosed) to the duodenum and 43632 if the stomach is anastomosed to the jejunum.

43632 - Gastrectomy, partial, distal; with gastrojejunostomy

Plain English Description
A partial gastrectomy is performed to remove the lower (distal) portion of the stomach. An incision is made in the abdomen and the stomach exposed. The stomach is divided at the pylorus and mobilized to expose the left gastric artery. The vascular pedicle is clamped, the stomach contents evacuated, and the stomach decompressed. Branches of the left gastric artery are identified, divided, and suture ligated distal to the vascular clamp. The clamp is released and hemostasis verified. The proximal resection site is identified and marked with a suture. The distal point of the resection is identified and marked with noncrushing clamps. The stomach is divided and staples applied. The staple line is oversewn with sutures and hemostasis secured. The remaining stomach segment is aligned with the remaining segment of intestine and temporary stay sutures placed. The temporary sutures are replaced with running sutures and the stomach serosa approximated to the intestinal serosa. Report 43631 if the stomach is sutured (anastomosed) to the duodenum and 43632 if the stomach is anastomosed to the jejunum. Report 43633 if a Roux-en-Y reconstruction is performed. The partial distal gastrectomy is performed as described above. A segment of jejunum is selected and the peritoneal leaves of the mesentery incised vertically. Blood vessels are divided and suture ligated. The jejunal segment is divided. The efferent limb is anastomosed to the stomach. A window is made in the base of the transverse mesocolon for passage of the Roux loop. The afferent limb is anastomosed to the base of the efferent limb. The margins of the window in the transverse mesocolon are sutured to the Roux loop.

43610 - Excision, local; ulcer or benign tumor of stomach

Plain English Description
Local excision of an ulcer or tumor is performed. An incision is made in the abdomen and the stomach exposed. The stomach is palpated to identify the location of the ulcer or tumor. Depending on the location of the ulcer or tumor, the stomach may be mobilized to provide better access to the site of the lesion. Gastric arteries are identified and the vascular pedicle clamped. The stomach is incised and blood evacuated from the stomach. The ulcer or tumor is located and excised. Report 43610 for local excision of an ulcer or benign tumor and 43611 for local excision of a malignant tumor.
 

DiCamille

Member
I agree with 43610 being the closer match in description and work involved. Why are you thinking modifier 52 would be needed?

If there was an unlisted procedure code of the stomach I'd say use that and submit documentation that it was very similar to 43610. I feel I could support this if questioned.

Good morning Laureen ~

Thanks for such a speedy response and your help!

Modifier 52 was a thought because there wasn't really a tumor or a mass being excised.
 

Laureen

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It says ulcer or tumor so I'd treat it like an ulcer.
 
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