Paula Wright, CPC, CPC I, CEMC, CPMA

Transcription

1 Paula Wright, CPC, CPC I, CEMC, CPMA

2 Abdominal Aortic Aneurysm Repairs Open direct or endovascular? Was there surgical exposure of an artery? Unilateral or bilateral access (endovascular)? Introduction of catheters? Type of device? 2

3 34800 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorta aortic tube prosthesis 3

4 34802 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (1 docking limb) 4

5 34803 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (2 docking limbs) 5

6 34804 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis 6

7 34805 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto uniiliac or unifemoral prosthesis 7

8 34825 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel 8

9 Example She then had an Endurant main body device advanced without difficulty through a left sided approach using the Endurant 28x16x145 length device. The contralateral gate was then cannulated from the right side using a guidewire and glide catheter. A contralateral limb was then placed using a 16x16x124 cm length device just proximal to the iliac bifurcation on the right side. On the left she had a distal type 1 endoleak that required the placement of a distal extension limb. Using an Endurant 24x24x82 cm length device was deployed 34802,

10 1 Example This was done in both groins, and after that, a 12 French sheath was placed on the right groin, and on the left, we inserted directly an Endurant 23 rnrn proximal diameter, 166 length, 16 distal diameter Endograft. After confirming the position of the renal arteries and the left hypogastric artery, we deployed the Endograft according to instructions for use without any complications. Using the right groin access, we cannulated the contralateral gate, and after confirming intragraft placement of the wire, we advanced an introducer and then a right iliac limb, 16 proximal diameter, 13 distal diameter, 124 in length, and deployed making sure that the right hypogastric artery remained patent. Balloon angioplasty was then performed within the

11 2 Example..opened the groins surgically in a routine manner and put 5 frnech sheaths within at the level of the common femoral artery. Two superstiff wires went up. We brought the main body from the left side, and pigtailed in from the right side. We did our initial angiogram, at the level of the renals. We went up with the ipsilateral limb, got that into position, marked the level of the internal iliac arteries with an angiogram, deployed very nicely and then went up the contralateral limb and did an angiogram and marked the origin of the internal iliac on that side and deployed the contralateral limb , x2 11

12 34830 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis aorto bi iliac prosthesis aorto bifemoral prosthesis 12

13 35081 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta. 13

14 35082 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm 14

15 35091 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) 15

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18 35102 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels (common, hypogastric, external) for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) 18

19 35301 Thromboendarterectomy, including patch, if performed; carotid, vertebral, subclavian, by neck incision 19

20 The physician makes an incision in the skin of the neck over the site of plaque or abnormal lining of the carotid, vertebral, or subclavian artery. The vessel is isolated and dissected from adjacent critical structures and vessel clamps are applied. A temporary vascular shunt may be placed, bypassing the area and allowing blood supply to continue uninterrupted during the procedure. The vessel is incised. Using a blunt, spatula like tool, the plaque and the vessel lining are separated from the artery and removed. The edge of the normal artery lining may be sutured to the artery wall to prevent separation when blood flow resumes. After the plaque and lining are removed, a patch graft taken from another portion of the patient's body, a cadaver, or a synthetic source may be applied and sutured to the vessel. This enlarges the diameter of the artery. The vessel clamps are removed and the skin incision is repaired with layered closure 20

21 35556 Bypass graft, with vein; femoralpopliteal Bypass graft, with other than vein; femoral popliteal 21

22 Through incisions in the skin of the leg overlying the femoral and popliteal arteries, the physician isolates and dissects a section of artery that is damaged or blocked. The physician creates a bypass around the superficial femoral artery, using a harvested vein and one of two methods of repair. Once vessel clamps have been affixed above and below the defect, the superficial femoral artery may be cut through above the damaged or blocked area and sutured to one end of a harvested vein. The vein is passed through a tunnel down the thigh muscles and behind the knee and sutured to the popliteal artery. In the second method, the ends of the harvested vein are sutured into the side of the femoral and popliteal arterial walls, resulting in a bypass of the damaged area. When the clamps are removed, the section of vein forms a new path through which blood can easily bypass the blocked area. The blocked or damaged portion of artery is not removed. After the graft is complete, the skin incisions are repaired with layered closures. 22

23 35583 In situ vein bypass; femoral popliteal In situ vein bypass; femoral anterior tibial, posterior tibial, or peroneal artery In situ vein bypass; popliteal tibial, peroneal 23

24 Through an incision in the skin of the leg overlying the greater saphenous vein, the physician isolates and dissects the greater saphenous vein from adjacent critical structures from the upper thigh to the level of the knee. Vessel clamps are affixed above and below the site of the anastomosis to the femoral and popliteal arteries. All side branches of the saphenous vein are tied off. The vessel's valves are destroyed. The upper end of the saphenous vein is divided and sutured into the femoral artery end to end or end to side. The lower end is divided and sutured into the popliteal artery end to end or end to side. The clamps are removed, and blood flows backward toward the feet, as if the vein were an artery. 24

25 35566 Bypass graft, with vein; femoralanterior tibial, posterior tibial, peroneal artery or other distal vessels Other than vein 25

26 Through incisions in the skin of the leg overlying the superficial femoral artery, the physician isolates and dissects sections of the femoral and anterior tibial, posterior tibial, or peroneal arteries. The physician creates a bypass around the affected artery using a harvested vein. Once vessel clamps have been affixed above and below the defect, the superficial femoral artery may be cut through above the damaged area and sutured to one end of a harvested vein, which is passed through an intramuscular tunnel and sutured to the anterior tibial, posterior tibial, peroneal, or other distal vessel. In the second method, the ends of the harvested vein are sutured to the side of the femoral artery and anterior tibial, posterior tibial, peroneal, or other distal vessel wall, resulting in a bypass of the damaged area. When the clamps are removed, the section of vein forms a new path through which blood can easily bypass the blocked area. The blocked or damaged portion of artery is left in place and not removed. After the graft is complete, the skin incisions are repaired with layered closures. 26

27 35558 Bypass graft, with vein; femoralfemoral Bypass graft, with other than vein; femoral femoral 27

28 Through incisions in the skin of the upper thighs, the physician isolates and dissects a section of the femoral arteries. The physician creates a bypass using a harvested vein. Once vessel clamps have been affixed above and below the area of anastomosis, the femoral artery may be cut through below the damaged area and sutured to one end of a harvested vein, which is sutured to the femoral artery in the opposite leg, resulting in a bypass of the damaged or blocked area. When the clamps are removed, the section of vein forms a new path through which blood can easily bypass the blocked area. The blocked or damaged portion of the artery is not removed. After the graft is complete, the skin incisions are repaired with layered closures 28

29 35565 Bypass graft, with vein; iliofemoral Bypass graft, other Than vein; iliofemoral 29

30 Through incisions in the skin of the lower abdomen overlying the iliac artery and in the skin of the upper thigh overlying the femoral artery, the physician isolates and dissects a section of common iliac artery. The physician creates a bypass around the iliac artery, using a harvested vein and one of two methods of repair. Once vessel clamps have been affixed above and below the defect, the iliac artery may be cut or tied off with sutures above the damaged area and sutured to one end of a harvested vein. The graft is passed through a tunnel on the inside of the upper thigh and is sutured to the side of the femoral artery. In the second method, the end of the harvested vein is sutured to the side of the iliac artery. Either method results in a bypass of the damaged area. When the clamps are removed, the section of vein forms a new path through which blood can easily bypass the blocked area. After the graft is complete, the skin incisions are repaired with layered closures. 30

31 35571 Bypass graft, with vein; popliteal tibial, peroneal artery or other distal vessels other than vein 31

32 Through incisions in the skin of the leg overlying the popliteal arteries, the physician isolates and dissects a section of arteries from adjacent critical structures. The physician creates a bypass around the artery, using a harvested vein and one of two methods of repair. Once vessel clamps have been affixed above and below the defect, the popliteal artery may be cut through above the damaged area and sutured to one end of a harvested vein, which is sutured to the tibial, peroneal, or other distal artery. In the second method, the ends of the harvested vein are sutured into the side of the popliteal and the tibial or peroneal arterial wall resulting in a bypass of the damaged area. When the clamps are removed, the section of vein forms a new path through which blood can easily bypass the blocked area. After the graft is complete, the incisions are repaired with layered closures. 32

33 Bypass Graft Bypass graft, with other than vein; axillary femoral femoral 33

34 Through an incision in the skin of the axilla and both upper thighs, the physician creates a bypass around a section of lower aorta that is damaged or blocked, using a synthetic graft. Once vessel clamps have been affixed above and below the defect, the synthetic graft is sutured to the side of the axillary artery and passed through a subcutaneous tunnel to the upper thigh where it is sutured end to end or end to side to the femoral artery. A second synthetic graft is sutured end to side to the femoral artery and passed through another subcutaneous tunnel to the opposite thigh where it is sutured end to end or end to side to the femoral artery. The section of blocked artery is not removed. When the clamps are removed, the two synthetic grafted limbs form a new path through which blood can easily bypass the blocked area. After the graft is complete, the skin incisions are repaired with layered closures. 34

35 Carotid Artery Stenting Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; without distal embolic protection 35

36 Carotid Artery Stenting 36

37 The physician places an intravascular stent percutaneously through a catheter into the cervical carotid artery. A needle is inserted through the skin into the access blood vessel, usually the brachial or femoral artery. A guidewire is threaded through the needle into the cervical carotid artery and the needle is removed. Long sheaths or guiding catheters are advanced into the stenosed cervical carotid artery. A filter protection device may be inserted distal to the stenosis to capture emboli. After filter opening, predilation of the stenosis with angioplasty balloons may be performed. A catheter with a stent transporting tip is threaded over the guidewire into the vessel, and the wire is extracted. The catheter travels to the point where the vessel needs additional support. The compressed stent is passed from the catheter out into the vessel, where it deploys, expanding to support the vessel walls. The catheter is removed and pressure is applied over the puncture site 37

38 35472 Transluminal balloon angioplasty, percutaneous; aortic 38

39 ENDOVASCULAR REVASCULARIZATION 39

40 ENDOVASCULAR REVASCULARIZATION Three arterial vascular territories Iliac Femoral/Popliteal Tibial/Peroneal»Angioplasty»Atherectomy»Stent placement 40

41 Iliac Territory Femoral/Popliteal Territory Tibial/Peroneal Territory 41

42 ENDOVASCULAR REVASCULARIZATION Iliac Territory Common Iliac Internal Iliac External Iliac 42

43 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty with transluminal stent placement(s), includes angioplasty within same vessel, when performed Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral vessel; with transluminal angioplasty with transluminal stent placement(s), includes angioplasty within same vessel, when performed 43

44 A patient with no prior angiograms is scheduled for angiography and possible intervention due to right leg pain. The physician punctures the left common femoral and performs an aortogram and bilateral extremity angiograms. These reveal stenosis of the right iliac vessels. The physician therefore performs angioplasty of the right common iliac and angioplasty and stent placement in the right external iliac (rt external iliac), (rt common iliac), 75625,

45 A patient with no prior catheter angiograms is scheduled for angiography and possible intervention. The physician punctures the right femoral artery and performs an abdominal aortogram and bilateral lower extremity angiograms. The angiograms reveal stenosis of the left common iliac and the right external iliac. The physician performs angioplasty and stent placement in the left common iliac and angioplasty in the right external iliac, all via the right common femoral access lt common iliac, rt external iliac, 75625,

46 ENDOVASCULAR REVASCULARIZATION Femoral/Popliteal Territory Common Femoral Lateral Circumflex Profunda Femoris Medial Descending Lateral Descending Perforating Branches Superficial Femoral Popliteal Geniculate 46

47 37224 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral, initial vessel; with transluminal angioplasty with atherectomy, includes angioplasty within the same vessel, when performed with transluminal stent placement(s), includes angioplasty within same vessel, when performed with transluminal stent placement(s) and atherectomy, includes angioplasty within same vessel, when performed 47

48 A patient with no prior angiograms undergoes an abdominal aortogram and bilateral lower extremity angiogram via right femoral access, which reveals stenosis of the left superficial femoral artery (SFA). The physician therefore performs angioplasty and stent placement in this vessel , 75625,

49 A patient with prior angiograms that showed lesions of the right SFA and popliteal. He returns for intervention. Via left femoral access, the physician performs a right lower extremity angiogram, followed by angioplasty and stent placement in the right SFA and angioplasty of the right popliteal

50 ENDOVASCULAR REVASCULARIZATION Tibial/Peroneal Territory Common Tibio peroneal Trunk Anterior Tibial Peroneal Posterior Tibial 50

51 37228 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal angioplasty with atherectomy, includes angioplasty within same vessel, when performed with transluminal stent placement(s), includes angioplasty within same vessel, when performed with transluminal stent placement and atherectomy, includes angioplasty within same vessel, when performed 51

52 37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal, unilateral, each additional vessel; with transluminal angioplasty with atherectomy, includes angioplasty within the same vessel, when performed Revascularization, with transluminal endovascular, stent placement(s), open or includes percutaneous, angioplasty tibial/peroneal, within the unilateral, same vessel, each when performed additional vessel; with transluminal angioplasty with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed 52

53 A patient has had prior angiograms showing severe disease of both lower legs and returns for intervention. The physician punctures the right common femoral artery and via antegrade approach, performs angioplasty of the anterior tibial artery and angioplasty and atherectomy of the posterior tibial artery. Then the physician punctures the left popliteal artery and via antegrade approach, performs angioplasty and stent placement in the left peroneal artery rt posterior tibial, lt peroneal, rt anterior tibial 53

54 A patient has had prior angiograms showing stenosis of the infrapopliteal vessels in the right leg. The physician punctures the right common femoral and deploys a drug eluting stent in the right tibioperoneal trunk. He also performs angioplasty of the right posterior tibial artery

55 3 Setup shots were done from the common femoral region demonstrating high grade disease in the popliteal of the left lower extremity. A wire was then placed down the posterior tibial and an SS Fox Hollow cutter was then utilized and multiple passes were made over below knee popliteal region with excellent results. Then attention was turned to the posterior tibial artery, which was done with the same cutter. Following this, a 3.0 x 100 balloon was utilized and the posterior tibial was ballooned at about 10 atmospheres. 55

56 3 Then attention turned to the peroneal artery. This was cut with the SS Fox Hollow cutter and then ballooned with a 2.5x 150 NanoCross balloon

57 Example A 7 French Ansel sheath was placed into the left common femoral region from the right groin. Catheter was placed in the popliteal, then an Xpeedior AngioJet catheter was utilized and at that time, we made multiple passes. Flow was restored in the vessel with stenotic tissue proximally and distally. We decided that we would stent over the remaining stenosis. A 6 x 20 balloon was then utilized to pre dilate that area where there was remaining stenosis and then a Supera stent was deployed extending past

58 Atherectomy 0234T Transluminal peripheral atherectomy, including radiological supervision and interpretation; renal artery 0235T visceral artery 0236T abdominal aorta 0237T brachiocephalic trunk and branches, each 0238T iliac artery, each vessel (above the inguinal ligaments 58

59 0238T Atherectomy provided in iliac above the inguinal ligament 59

60 60

61 Colectomy and Proctectomy 61

62 Stapler 62

63 63

64 44140 Colectomy, partial; with anastomosis Laparoscopic 64

65 Hemicolectomy 65

66 Colectomy 66

67 I then took the left colon proximal and distal to the mass which allowed us a little bit of mobility, took the mesentery of the colon thus freeing the mass inferiorly. We were able to remove the mass intact. This brought the tranvserse colon to the descending colon, I performed a side toside hand sewn anastomosis with an outer layer of silk and an inner layer of Maxon

68 44141 Colectomy, partial; with skin level cecostomy or colostomy 68

69 The physician resects a segment of colon and brings the proximal end of colon through the abdominal wall onto the skin as a colostomy. The physician makes an abdominal incision. Next, the selected segment of colon is isolated and divided proximally and distally to the remaining colon and removed. The proximal end of colon is brought through a separate incision on the abdominal wall and onto the skin as a colostomy. Alternately, the remaining bowel ends may be reapproximated and a loop of colon proximal to the anastomosis brought through a separate incision on the abdominal wall onto the skin as a loop colostomy. 69

70 44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) Laparoscopic 70

71 The physician resects a segment of colon and brings the proximal end of colon through the abdominal wall onto the skin as a colostomy. The physician makes an abdominal incision. Next, the selected segment of colon is isolated and divided proximally and distally to the remaining colon and removed. The proximal end of colon is brought through a separate incision on the abdominal wall onto the skin as a colostomy. The distal end of colon is closed with staples or sutures and left in the abdomen. The initial incision is closed 71

72 44144 Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula 72

73 The physician resects a segment of colon. The proximal and distal ends of colon are brought through the abdominal wall onto the skin as a colostomy and mucus fistula. The physician makes an abdominal incision. Next, the selected segment of colon is isolated and divided proximally and distally to the remaining colon and removed. The proximal end of colon or terminal ileum and the distal end of colon are brought through separate incisions on the abdominal wall onto the skin as an ileostomy or colostomy and mucus fistula. The initial abdominal incision is closed. 73

74 44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) Laparoscopic 74

75 The physician resects a segment of distal colon or rectum and performs a low colorectal anastomosis in the pelvis. The physician makes an abdominal incision. Next, the distal colon and rectum are mobilized and the selected segment divided proximally and distally to the remaining colon. An anastomosis is created between the proximal colon and remaining rectum in the pelvis with staples or sutures. The incision is closed. 75

76 44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy Laparoscopic 76

77 The physician resects a segment of distal colon or rectum and performs a low colorectal anastomosis in the pelvis and creates a proximal colostomy. The physician makes an abdominal incision. Next, the distal colon and rectum are mobilized and the selected segment of diseased colon and/or rectal tissue is removed. The new ends are brought together and an anastomosis is done between the colon and the rectum low in the pelvis with staples or sutures (coloproctostomy). A loop of colon above the newly sutured anastomosis is brought out through a separate incision in the abdominal wall and fixed there so the colon will empty through this artificial opening in the skin as a colostomy, usually temporary, to divert the fecal stream while the anastomosis heals. The initial incision is closed. 77

78 44147 Colectomy, partial; abdominal and transanal approach 78

79 The physician removes a segment of colon through a combined abdominal and transanal approach and reapproximates the remaining ends of the colon. The physician makes an abdominal incision. The distal colon and rectum are mobilized also by using a transanal approach. The segment of the colon to be eliminated is divided at the appropriate distal and proximal points and the remaining ends are anastomosed. The abdominal and transanal incisions are closed 79

80 44160 Colectomy, partial, with removal of terminal ileum with ileocolostomy Laprascopic 80

81 The physician makes an abdominal incision and removes a segment of the colon and terminal ileum and performs an anastomosis between the remaining ileum and colon. The physician makes an abdominal incision. Next, the selected segment of colon and terminal ileum are isolated and divided proximal and distal to the remaining bowel and removed. An anastomosis is created between the distal ileum and remaining colon with staples or sutures. The incision is closed. 81

82 44150 Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy Laparoscopic OR With rectum preserved 82

83 The physician removes the entire colon and performs an ileostomy or an anastomosis between the ileum and rectum. The physician makes an abdominal incision. Next, the colon is mobilized and the colorectal junction and terminal ileum is divided. The colon is removed. The terminal ileum is approximated to the rectum or brought out through a separate incision on the abdominal wall onto the skin as an ileostomy. The initial incision is closed. 83

84 44151 Colectomy, total, abdominal, without proctectomy; with continent ileostomy 84

85 The physician removes the entire colon and creates a reservoir of distal ileum (Kock pouch). The reservoir is brought out through the abdominal wall as a continent stoma. The physician makes an abdominal incision. Next, the colon is mobilized. The colorectal junction and terminal ileum is divided and the colon removed. The distal ileum is folded upon itself and approximated to form a pouch and valve. The distal end of the pouch is brought through a separate incision on the abdominal wall onto the skin as a continent ileostomy. The initial incision is closed. 85

86 44155 Colectomy, total, abdominal, with proctectomy; with ileostomy Laparoscopic 86

87 The physician removes the entire colon and rectum and brings the terminal ileum out through the abdominal wall onto the skin as an ileostomy. The physician makes an abdominal incision. Next, the colon and rectum are mobilized, the proximal rectum and distal ileum are divided, and the colon and proximal rectum are removed. The distal rectum is mobilized and removed through a perineal approach. The terminal ileum is brought out through a separate incision on the abdominal wall onto the skin as an ileostomy. The abdominal and perineal incisions are closed 87

88 44156 Colectomy, total, abdominal, with proctectomy; with continent ileostomy 88

89 44157 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed 89

90 44158 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed Laparoscopic 90

91 91

92 45110 Proctectomy; complete, combined abdominoperineal, with colostomy Laparoscopic 92

93 The physician removes the entire rectum and anus and forms a colostomy. The physician makes an abdominal incision. The proximal rectum is mobilized within the abdomen to the level of the sphincter muscles and the colon is divided above the pelvic brim. An incision is made around the anus from a perineal approach and the anus and distal rectum are dissected free of surrounding structures and the anus and rectum are removed. The proximal end of colon is brought out through a separate incision on the abdominal wall as a colostomy. The abdominal and perineal incisions are closed. 93

94 45111 Proctectomy; partial resection of rectum, transabdominal approach 94

95 The physician removes the proximal rectum. The physician makes an abdominal incision. The distal colon and rectum are mobilized and divided proximal and distal to the segment of interest. The colon and distal rectum may be reapproximated or the proximal end of colon may be brought out through a separate incision on the abdominal wall as a colostomy and the remaining rectum closed with staples or sutures. The initial incision is closed. 95

96 45112 Proctectomy, combined abdominoperineal, pull through procedure (eg, colo anal anastomosis) 96

97 The physician removes the rectum and performs an anastomosis between the colon and the anus. The physician makes an abdominal incision. The distal colon and rectum are mobilized within the abdomen to the level of the sphincter muscles. The colon is divided above the pelvic brim and the rectum at the level of the sphincter muscles and removed. The mucosa may be stripped from the remaining distal rectum from a perineal approach. The distal colon is pulled through the sphincter complex and approximated to the anus with sutures. The incision is closed. 97

98 45113 Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy 98

99 The physician removes the proximal rectum, strips the mucosa from the distal rectum and performs an anastomosis between an ileal pouch and the anus. The physician makes an abdominal incision. The distal colon and rectum are mobilized within the abdomen to the level of the sphincter muscles. The colon is divided above the pelvic brim and the rectum is divided above the sphincter muscles and removed. The mucosa of the distal rectum is stripped from a perineal approach. The distal ileum is folded upon itself and approximated in order to form a reservoir. The ileal pouch is pulled through the remaining muscular cuff of distal rectum and sutured to the anus. A loop ileostomy may be formed proximal to the anastomosis. The incision is closed. 99

100 45114 Proctectomy, partial, with anastomosis; abdominal and transsacral approach transsacral approach only (Kraske type) An incision is made posteriorly at the junction of the sacrum and coccyx. The coccyx is excised. Dissection is continued posteriorly to further mobilize the rectum. The rectum is divided distally and the excised segment is removed. The distal end of colon is approximated to the remaining rectal stump with sutures or staples. The incisions are closed. 100

101 45119 Proctectomy, combined abdominoperineal pull through procedure (eg, colo anal anastomosis), with creation of colonic reservoir (eg, J pouch), with diverting enterostomy when performed Laparoscopic 101

102 The physician surgically removes the rectum. The physician makes an abdominal incision, and the distal part of the diseased colon and rectum are mobilized down to the level of the anal sphincter muscles. The rectum is incised at the level of the sphincter muscles while the colon is incised above the pelvic brim where it is disease free. The diseased colon and rectum are removed. The free end of the distal colon is brought through the sphincter complex and approximated with the anus to form a colo anal anastomosis. The distal colon is folded and sutured in such a way as to create a colonic reservoir pouch. The physician may elect to bring a loop or end of the colon through a separate abdominal incision to create a stoma (enterostomy). 102

103 45120 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pullthrough procedure and anastomosis eg, Swenson, Duhamel, or Soave type operation) 103

104 The physician removes or bypasses the diseased rectal segment and performs an anastomosis of the colon and anus. The physician makes an abdominal incision. The rectum and distal colon are mobilized and the colon is divided just proximal to the diseased rectal segment. The rectal segment may be removed and the distal colon pulled through the sphincter complex and approximated to the anus with sutures from a perineal approach. Alternatively, the distal colon may be pulled down and approximated to the anus with sutures, bypassing the diseased rectal segment with a combined longitudinal anastomosis between the colon and the diseased rectal segment. The incision is closed. 104

105 45216 Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof 105

106 45130 Excision of rectal procidentia, with anastomosis; perineal approach abdominal & perineal approach 106

107 107

108 The physician removes a rectal prolapse through a perineal approach. The physician prolapses the rectum and colon through the anus. A circular incision is made through the distal rectum at the anorectal junction. The mesentery and blood supply to the prolapsed rectum is divided and the segment is telescoped out through the anus. The proximal rectum or colon is divided and the prolapsed segment is removed. The proximal end of rectum or colon is approximated to the anus with sutures or staples. 108

109 45160 Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach 109

110 The physician removes a rectal tumor through a transsacral or transcoccygeal approach. The physician makes an incision at the junction of the sacrum and coccyx. The coccyx is excised and dissection is continued posteriorly to mobilize the rectum. The tumor is identified, an incision is made in the rectum (proctotomy), and the tumor is excised. The rectum is closed with sutures or staples. The initial incision is closed. 110

111 45402 Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection Open 111

112 The physician completely mobilizes the rectum down to the pelvic floor and attaches the rectum to the sacrum using polypropylene mesh. The mesh is initially stapled to the sacral hollow and sutured on both sides of the rectum. The sigmoid resection is performed in conjunction with the proctopexy. Using a laparoscope, the physician mobilizes the sigmoid colon and rectum. The redundant segment of sigmoid colon and rectum are excised and an anastomosis is created between the remaining bowel ends with sutures or staples 112