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Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus, commonly referred to as the Ladd procedure, addresses a congenital anomaly known as intestinal malrotation. This condition arises when the intestines fail to properly rotate to the left of the superior mesenteric artery (SMA) during fetal development, specifically between the 4th and 12th weeks. The surgical intervention involves a midline abdominal incision to access the intestines. In cases where a midgut volvulus is present, the entire small bowel and transverse colon are carefully extracted from the abdominal cavity. The typical presentation of malrotation leads to a clockwise twisting of the intestines, necessitating the surgeon to untwist the bowel in a counterclockwise direction to alleviate the volvulus. Following this, the viability of the bowel is thoroughly inspected to ensure there is no compromise to its blood supply. The procedure also involves repositioning the cecum into the left upper quadrant and exposing the duodenum for a comprehensive examination along its entire length. The surgeon checks for any external obstructions caused by fibrous bands of tissue that may be present between the duodenum and the peritoneum, which are then lysed. Additionally, bands may be located at the ileum or jejunum, and if they are found to be attached to the gallbladder or liver, these are also lysed. To confirm the absence of internal obstructions, a nasogastric tube is passed through the duodenum. Furthermore, an incidental appendectomy is performed prior to closing the abdomen to mitigate the risk of damage to the appendiceal vessels during the lysis of bands.
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The Ladd procedure is indicated for the correction of malrotation of the intestines, which is a congenital condition that can lead to serious complications if not addressed. The following conditions warrant the performance of this procedure:
The Ladd procedure involves several critical steps to correct malrotation and address any associated complications. The following procedural steps are performed:
Post-procedure care following the Ladd procedure includes monitoring for any signs of complications such as infection, bowel obstruction, or ischemia. Patients are typically observed in a postoperative setting where vital signs are closely monitored. The nasogastric tube may remain in place for a short period to ensure proper bowel function and to prevent any potential complications. Patients may gradually resume oral intake as tolerated, and the surgical site is assessed for healing. Follow-up appointments are essential to evaluate the success of the procedure and to monitor for any recurrence of symptoms related to malrotation or volvulus.
| Short Descr | CORRECT MALROTATION OF BOWEL | Medium Descr | CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS | Long Descr | Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 96 - Other OR lower GI therapeutic procedures |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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