Gastroenterology Coding Alert

Your surgeon's op report plays crucial role.

When a physician closes a colostomy, resection and anastomosis of the bowel often accompanies the procedure. Often, you can make use of the surgeon's op note to guide you to the appropriate code, as it should describe any resection and anastomosis he performs with a colostomy closure during the same operative session.

Some situations, however, require closer examination. If you equip yourself with integral information, you should be counting your most desired dollars in no time at all.

Start Simple

Scenario 1: The GI surgeon performs coloproctostomy with colostomy (44146, Colectomy, partial; with coloproctostomy [low pelvic anastomosis], with colostomy) for a patient with colon cancer. Four months later, the surgeon closes the colostomy without bowel resection. What code should you report?

Solution 1: For a basic takedown of enterostomy without bowel resection, you would report 44620 (Closure of enterostomy, large or small intestine). Look for clues in the documentation, such as a description of taking down the stoma of the colon and sewing it back together. The surgeon may elect to perform the closure weeks or even months after the initial colostomy procedure.

It's important to check the operative report and see what the surgeon actually did, reminds Jan Rasmussen, president of Professional Coding Solutions in Eau Claire, WI. Coding Resection? Zero In on Location

Scenario 2: The GI surgeon performs a colostomy closure and resects a large segment of rectosigmoid before completing the anastomosis. He takes down the stoma and resects a small piece of bowel from it. He then goes down to the rectum/ sigmoid, and resects a large piece of bowel, hooking the two ends together. There is only one anastomosis, and one diagnosis (V55.3, Colostomy status). What code should apply?

Solution 2: If the surgeon performs resection and anastomosis of the bowel at the same time as enterostomy takedown, you will report either 44625 (...with resection and anastomosis other than colorectal) or 44626 ( ...with resection and colorectal anastomosis [e.g., closure of Hartmann type procedure]), depending on which portion of the bowel the surgeon addresses.

Distinction: You would report 44625 if the surgeon performs the resection anywhere besides the colorectal area -- for instance, the sigmoid colon. You would instead code 44626 if the surgeon resects the colon in the colorectal area.

Colorectal surgeries are generally more difficult because of the lower pelvic nature of the exposure and subsequent anastamosis, according to M. Tray Dunaway, MD, FACS, CSP, a surgeon, author, speaker and coding educator with Healthcare Value, Inc. in Camden, SC. For this reason, you should be paid a higher rate for 44626 than for 44625.

Tip: Never second-guess your surgeon. If the resection isn't included in the surgeon's narrative, you should simply not bill for it. It's also a good move to double-check the pathology report, and look for anything that might suggest the surgeon performed a resection. Then discuss it with your surgeon.

Cost: The current CMS fee schedule assigns 14.43 physician work relative value units (RVU) to colostomy closure 44620. CPT 44625 has 17.28 RVUs, while 44626 has 27.90 RVUs. You're risking large amounts of money if you're not careful with your coding.

Note Same-Session Situations

Scenario 3: The surgeon sees a patient with severe abdominal pain, a history of diverticulosis and rebound tenderness. She performs an exploratory laparotomy of the abdomen and identifies severe diverticulitis -- in this case, a large abscess in the sigmoid colon. The surgeon decides not to resect the sigmoid and instead performs a transverse loop colostomy (44320, Colostomy or skin-level cecostomy). In addition, the surgeon drains the peritoneal abscess (49020, drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open). After a few months, when the inflammation and infection have resolved, the surgeon performs sigmoid colectomy with primary anastomosis. He also decides to close the original loop colostomy  simultaneously. How should you report it?

Solution 3: Since the surgeon performs the anastomosis and takedown during the same session, report both 44145 (Colectomy, partial; with coloproctostomy [low pelvic anastomosis]), and 44620. Adding modifier 59 (Distinct procedural service) to 44620 should indicate that the closure of the original loop colostomy occurred at a different site than the partial colectomy of the sigmoid colon.

Another way: If the surgeon performs the anastomosis and waits to take down the original colostomy until a later date, you would code 44145 for the initial surgery. When the takedown of the initial colostomy at a later date occurs, then you'd report 44620 without modifier 59.

Do this: Make sure you append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the resection code 44145 if a resection occurs within the global period of the loop colostomy.