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Posted By Maria on 12-11-2019, 12:54:42 in Ob-Gyn
Hello Melanie,

Would you please help me with a CPT for this procedure?


INDICATIONS:
80 yo with a pelvic mass and colonoscopy showing recurrent uterine cancer here for OR removal
 
FINDINGS:
Mass is sigmoid colon and anterior to colon / posterior to vagina
 
SPECIMEN:
Sigmoid colon with mass
 
 
PROCEDURE:
 
After assuring informed consent the patient was taken back to the operating suite and induction of general anesthesia was done. The patient was placed in the modified dorsal lithotomy position in Allen stirrups then prepped and draped in the normal sterile fashion.
 
A midline vertical skin incision was made from the symphysis pubis up to the umbilicus. The incision was carried down to the fascia with the bovie cautery. The fascia was then incised and the incision was extended superiorly and inferiorly. The rectus muscles were separated in the midline. The peritoneum was identified and entered sharply, then carried superiorly and inferiorly with good visualization of the bladder.
 
The bookwalter retractor was then placed and attention was turned to the pelvis. The bowel was then packed back and the retroperitoneal spaces were opened bilaterally. The ureters were identified bilaterally. The mass was noted and the recto-vaginal space was opened. The bilateral rectal spaces were opened. The proximal portion of the colon was transected with a GIA 75 stapler. The ligasure came through the mesentery of the bowel posterior. The colon was brought up and the tissue and mass was dissected around this circumferentially. The distal colon was transected with a contour TA green stapler. The sigmoid colon and mass was removed and sent to path. The case was turned back to Dr. X for re-anastamosis and closure
 
 Thanks as Always, Maria
 
Comments (1)
Posted By Melanie Witt on 12-19-2019, 13:15:05
Sounds like co-surgery with the code 44140. The mass is described as being on the colon segment that was removed so you don't get a separate code for that.
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