General Surgery Coding Alert

Don't overlook associated procedures, or you'll be giving up reimbursement

When reporting colectomy, chances are you can upcode from a basic partial colectomy and increase the reimbursement your surgery practice collects if the report contains any of the following six terms: cecostomy, colostomy, ileostomy, or ileocolostomy, coloproctostomy and splenic flexure.
 
Here are five expert-approved tips to make the most of your colectomy claims:

1. Begin With 44140

To report an open, partial colectomy only, you should choose 44140 (Colectomy, partial; with anastomosis), says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. During this procedure, the surgeon removes the diseased section of colon and reattaches the distal and proximal ends of the remaining colon.
 
Unique approach means unique coding: If the surgeon chooses to perform a partial colectomy and anastomosis by abdominal and transanal approach, you should select CPT 44147 (... abdominal and transanal approach) rather than 44140.
 
Look for coloproctostomy first: When reviewing a colectomy operative report, the first "additional" procedure you should look for is a coloproctostomy, or low pelvic resection and anastomosis. For coloproctostomy with colectomy, report 44145 (... with coloproctostomy [low pelvic anastomosis]).

2. Add Choices With Colostomy

Next, you should search the documentation for evidence of a colostomy. During this procedure, the surgeon diverts the fecal stream away from the site of the anastomosis to facilitate healing.
 
For a colostomy only with partial colectomy and anastomosis, choose 44141 (... with skin-level cecostomy or colostomy).
 
In some cases, the surgeon may perform an "end colostomy," or Hartmann procedure, during which he brings the proximal end of the colon to the skin surface as a stoma, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock. This differs from the more typical "loop" colostomy described by 44141: Loop colostomy implies that only part of the wall of the colon is opened (usually the antimesenteric wall), and the colon is not completely transected, Barone continues. Therefore, you should report an end colostomy using 44143 (... with end colostomy and closure of distal segment [Hartmann type procedure]) rather than 44141.
 
If the surgeon performs both colostomy and coloproctostomy, you should call on 44146 (... with coloproctostomy [low pelvic anastomosis], with colostomy).

3. For Mucofistula With Colostomy, Jump to 44144

Don't stop reading the operative report when you decide on the type of colostomy the surgeon performed: There's another option, possibly further on in the documentation, to consider.
 
Along with end colostomy, the surgeon may create a mucofistula, or a "mucus fistula," which brings the proximal end of the now nonfunctional colon remainder to the skin level, Dunaway says. To report such a procedure, choose 44144 (... with resection, with colostomy or ileostomy and creation of mucofistula).
 
44144 can also include ileostomy: Code 44144 can describe the creation of mucofistula with either end colostomy or ileostomy (when a portion of the small intestine is brought to the skin).

4. Ileum Removal Should Clue You to 44160

Examine the operative report extra closely if the surgeon has anything to say about the ileum. If the surgeon removes a portion of the ileum, followed by ileocolostomy, you should report 44160 (Colectomy, partial, with removal of terminal ileum with ileocolostomy). And, as mentioned above, ileostomy with the formation of mucofistula calls for 44144.

5. Keep an Eye on the Splenic Flexure

When reporting colectomy, also be on the lookout for evidence that the surgeon freed or "mobilized" the splenic flexure (the left, bent segment of the colon that links the transverse and descending colon). If he has done so, you may report the add-on code +44139 (Mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]) in addition to the appropriate colectomy code (44140-44160), says Terry A. Fletcher, BS, CPC, CCS-P, CCS, healthcare coding consultant, president and CEO of Terry Fletcher Consultants, Laguna Beach, Calif., and an AAPC National Advisory Board member since 2002.

Use Cash to Convince

You should stress to your surgeons the importance of clear and complete operative notes so that you - the coder - can choose codes effectively. And if you think surgeons need convincing, show them the numbers.
 
Example: Suppose the surgeon performs colectomy with coloproctostomy, but fails to document the latter. Without evidence of the coloproctostomy, the coder will probably choose 44140, which pays about $784. But if the coder knew about the coloproctostomy and correctly chose 44145, the practice would receive about $1,000, based on national Medicare averages - an increase of over $200.
 
Solution: Encourage surgeons to dictate operative notes completely and to use CPT terminology.
 
Even better, Dunaway says, sit down with your surgeon and have him make sketches of what he removed, brought up to the skin level as a colostomy/mucus fistula, what suture/staple lines he created, and the location of anastomoses to clarify the procedure rather than relying on simple verbal description.
 
For example, the surgeon may say she performed a "standard right hemicolectomy," which typically includes the removal of the ileum and the formation of an ileocolostomy. If the documentation doesn't mention the ileum removal and ileocolonostomy specifically, the coder could easily choose 44140 over the correct code, 44160.