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Trauma Surgery: Ins and Outs of Major Surgery

Tammy Thomas COC, CPC, CMC, CGSC, CPMA, AAPC Associate

Even the slightest accident can cause major trauma.

Motor Vehicle Accidents

Stabbings

Blunt force / seatbelt

ATV Accidents Bicycles

GSW

Skateboarding Car vs Pedestrian

And SO MUCH MORE!

Most asked questions

• What is damage control surgery/laparotomy?

• Why use a temporary closure?

• What is a poor mans vac?• What is allowed as a

laparotomy reopening?• What is an abdominal

washout?• Can the physician receive

payment for reopening the laparotmy ?

• Final abdomen closure… code what?

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Performed usually in multi-stages, but not always

Primary Goal, in as little time as possible, is to avoid or control:

vExcessive blood lossvCavity contamination vHemorrhagic shock or sepsis vComplications of hypothermiavAcidosisvCoagulopathy

1st Stage

Hemorrhaging is stopped Temporary wound closuresLigation of bleeding vesselsChest or Abdomen packingVascular Shunts if neededGI decontamination by closure of any

lacerations or creating a temporary stoma

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Resuscitation Stage

Correction of :vmetabolic acidosisv anemiav coagulopathyv volume replacementv ventilation and vasopressure supportv ruling out massive tissue damage that would

lead to edema and/ compartment syndrome

Subsequent Stages

v operative management in a stable patientv re-establishes bowel continuity if able v looks for any missed injuriesv any vascular shunts that may have been

placed are repaired properlyv any orthopedic or plastic procedures are

initiated

Due to the complexity of damage control and the wide range of injuries a physician may encounter, there is no one CPT that can adequately describe all the potential combinations of codes.

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49000 Exploratory laparotomy, exploratory celiotomywith or without biopsy(s) (separate procedure)

The term “separate procedure” refers to a complete procedure that

stands alone…

49000 describes a procedure where nothing is repaired, reconstructed, removed and is normally billed alone.

Some surgeons will give the full details of opening the abdomen and all the devices they used to hold it open and then report a negative laparotomy.

Since most damage control has some sort of procedure this code would not apply.

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Why use a temporary closure?

Due to the patients condition it may require that closure of skin, subcutaneous tissue, muscle and fascia be delayed, resulting in the abdominal wound be left open.

The contents of the abdomen will be protected by the application of various methods to contain sterility, moisture and heat.

What is a poor man’s vac?

This is a typical temporary closure of alaparotomy.

It usually consists of multiple ABD pads or a sponge, drains and a thin layer a of an vapor-permeable membrane. ( a membrane, usually transparent, that allows oxygen and water vapor to pass through it.)

There is NO code for temporary closure

BUUUUTTTTT>>>>>>

Some codes may be uses if a negative pressure wound dressing is applied.

Ex. 97605 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

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Poor Man’s Vac

Negative Pressure Wound Vac

Re-opening recent laparotomy

Packing removed Abdomen re-explored

Procedures completed or reassessed Abdominal washout

Fascial closure

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49002Reopening of recent laparotomy

When the patient is appropriately prepped and anesthetized, the provider makes an incision through the previous abdominal incision. He examines the organs and the structures for evidence of infection or bleeding. He ties off any bleeding vessels and takes cultures from potential sites of infection. He may drain fluid from the abdomen or perform lavage, washing out the abdominal cavity with water or saline solution, a sterile salt solution. The provider then irrigates the wound, checks for bleeding, removes any instruments, and closes the incision.

What is an abdominal washout?

As seen in the definition for 49002, it is when the physician performs a lavage usually with saline solution to check the abdominal cavity.

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40-year-old gunshot wound patient is taken to the operating room for a panned re-opening of a recent laparotomy to examine the progress

of healing.1

The surgeon completes an abdominal exploration; the small bowel is examined, revealing the site of the anastamosis to be completely intact with no evidence of a leak or vascular compromise. The surgeon irrgates the abdomen and then applies vacuum-assisted wound drainage before closing the wound again.1

A 38-year-old motor vehicle crash patient with multiple injuries initially undergoes a damage-control laparotomy with direct repair of torn mesenteric blood vessels, small bowel resection without reconstruction, and temporary abdominal closure using a vacuum-assisted wound drainage device.

On hospital day three, following resuscitation in the ICU, the patient undergoes re-exploration of the laparotomy, debridement/resection of the previously stapled ends of the bowel, and anastomosis of the small intestine, again with temporary abdominal closure. On the fifth day, the surgeon completes an abdominal exploration to confirm anastomoticintegrity, irrigates the abdomen and applies a vacuum-assisted wound drainage as part of the progression to fascial and skin closure when the timing is appropriate.

What are you reportable codes?

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DAY 1 44120-523522197606

Modifier 52- it was not reconstructed

DAY 3

44120-5897606

DAY 5

49002-5897606

At some point the abdominal fascia will be closed, leaving only the superficial wound.

When the procedure involves only the wound vac therapy and “active wound management” but the fascia of the abdomen remains closed, or the granulation of tissue of the abdominal wall is not entered to gain access to the abdomen, the appropriate code to report is 97606 plus any applicable wound debridement codes. (11042-11047)

You should NOT report 49002 if the abdominal cavity is not entered.

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A 32-year-old gunshot wound patient undergoes initial laparotomy for repair of stomach and liver, with debridement of the liver and packing, plus placement of negative pressure dressing for temporary closure.

The next day, the patient is re-explored and the liver packing is removed with no other injuries found, but the abdomen still cannot be closed. Over the next three days the patient is managed aggressively in the ICU, including diuresis, and on day 6, the patient was returned to the operating room for final inspection, wash-out, debridement, and closure of the abdominal fascia.

DAY 1 4736143840-5197606

DAY 2

47362-5897606

DAY 6

49002-58

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What’s Next??The final closure… sewing it up…

closing that sucker!

It is a delayed closure…

May abdominal wound need some sort ofdebridement prior to or at the time of closure.

CPT codes – 11042-11047

Some open abdomens can be malipulated by rearranging the fascial edges, subcutaneous tissue and skin and then closed primarily.

CPT code 49900, suture, secondary, of abdominal wall for evisceration or dehiscence.

Skin grafts may also be used to accomplish final closure.

• Autograft – 15100-15005• Tissue cultured skin – 15150-15152• Skin substitute – 15271-15274

If the area to be grafted needs incisional or excisional procedures to properly prepare the site use codes 15002-15005

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Common Complication

Abdominal wall loss Contracture of abdominal muscle

This entails a more complicated procedure called component seperation is used to properly close the large fascial gaps or ventral hernias. Use the code 15734,Muscle, myocutaneous, or fasciocutaneous flap; trunk. It is used twice to represent both sides of the abdomen.2

It doesn’t have to always be an accident though…

Stomach ulcers

Colon ComplicationsCancers

Trauma injuries and scenarios are never ending. If you have a specific question I will do my very best to assist you.

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Questions… Answers…

• 1. http://bulletin.facs.org slides 22, 24, 27, 28

• 2. www.facs.org/ahp/pubs/tips/tips0911.pdf