General Surgery Coding Alert

Reporting partial colectomies can be difficult due to the clinical nature of the procedures. For example, most partial colectomies typically involve intestinal anastomosis and/or colostomy. Some of these procedures also include mucofistulas and ileocolostomies. Also, partial colectomies differ according to how the colon was approached and the section of colon removed. A coder unfamiliar with the anatomy of the digestive system may confuse the proper partial-colectomy code with another of the several procedures in CPT that include partial colectomy. A poorly written operative report can likewise result in incorrect coding.
Distinguishing Basic and Other Colectomies  
Partial-colectomy codes are found in the Digestive System/Surgery section of CPT under "Intestines (Except Rectum)." Although partial colectomy always involves resection, CPT does not use this term. Instead, colectomies make up the latter two-thirds of the "excision" subcategory. Of these codes, eight describe partial colectomies.
 
Code 44140 (colectomy, partial; with anastomosis) describes the basic partial colectomy, in which the diseased section of colon is removed and the distal and proximal ends of the remaining colon are stitched together.
 
Sometimes, the surgeon may suspect that the anastomosis will not take properly. In such cases, a cutaneous colostomy may be created with the colectomy. By creating the colostomy (typically, a loop colostomy), the surgeon diverts the fecal stream from the anastomosis, allowing it a better opportunity to heal. The remaining colon may also be stapled off to ensure that no intestinal contents (i.e., stool) disturb the healing anastomosis. When this type of colostomy is performed with a partial colectomy and anastomosis, 44141 (... with skin-level cecostomy or colostomy) should be reported. If, however, the distal segment of the colon is closed off and an end colostomy is created by bringing the proximal end of the colon to the skin surface, claim 44143 (... with end colostomy and closure of distal segment [Hartmann type procedure]).
 
Note: End colostomy is created by bringing an exposed end of resected colon to the skin surface. Loop colostomy involves pulling a loop of the remaining colon through a skin-level incision, where an opening is created to allow the rest of the colon to remain content-free.
 
Code 44144 (... with resection, with colostomy or ileostomy and creation of mucofistula) describes the creation of a mucofistula. The surgeon resects the diseased portion of colon (typically the left colon) but does not perform a primary anastomosis. There is enough distal colon remaining below the level of resection to reach skin level. This portion of distal colon is brought up into the incision and remains open. The proximal end of the functional colon is brought through a separate fascial opening to create an end colostomy. Subsequently, the mucus fistula is taken down for an anastomosis when a colostomy closure is performed.
 
If a low pelvic resection is performed and anastomosis between the colon and rectum is required, report  44145 (... with coloproctostomy [low pelvic anastomosis]). If the surgeon also creates a colostomy, 44146 (... with coloproctostomy [low pelvic anastomosis], with colostomy) should be used. If the surgeon used an abdominal and transanal approach to resect the colon, report 44147 (... abdominal and transanal approach).
 
If the surgeon performs a right hemicolectomy and removes the terminal ileum (an integral part of most right hemicolectomies), use 44160 (colectomy with removal of terminal ileum and ileocolostomy) -- even though the code descriptor does not state this code is used for partial (as opposed to total) colectomies.
 
Although the other codes listed here all clearly state "partial colectomy," the total colectomy codes (44150-44156) also clearly state "total." In fact, 44160 is the only code that does not include either "total" or "partial" in its descriptor. Therefore, it may be used when the terminal ileum is removed, regardless of whether a partial or total colectomy was performed with the removal of the ileum.
 
Finally, when left hemicolectomies are performed, the splenic flexure (the bent segment of the colon that links the transverse and descending colon) must sometimes be mobilized (i.e., freed). In such cases, report add-on code 44139 (mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]) with the appropriate partial colectomy code (44140-44160). The operative note should clearly indicate that this procedure was performed.
 
"Sometimes the surgeon has to free the splenic flexure because there may not be enough mobilized colon to perform an anastomosis," says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. Dunaway notes, "The splenic flexure is typically mobilized for left hemicolectomies or transverse colon resections." He adds that the hepatic flexure on the right side, which links the ascending colon and transverse colon, is usually easy to mobilize. Therefore, do not report this procedure separately.
Watch Op Note Terminology  
Because the codes listed above differ based on what the surgeon did and how he or she did it, the accuracy of the operative report is probably the most important factor in billing these procedures correctly, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.
 
For example, a surgeon performs a partial colectomy procedure on a female patient who has a carcinoma on the cecum, as well as a submucosal tumor in the right transverse colon. At the top of the operative report, the surgeon refers to the procedure as a right hemicolectomy, and later states that he hopes a "standard right hemicolectomy" will remove the submucosal tumor of the transverse colon and the carcinoma in the cecum.
 
Upon reading in the top of the op note that a right hemicolectomy was performed, the coder may well default to 44140, the basic partial colectomy code. That the surgeon refers to the procedure as a "standard" right hemicolectomy provides another (misleading) hint that 44140 should be used.
 
What the coder may not know, however, is that a standard right hemicolectomy typically involves the removal of the ileum and the formation of an ileocolostomy. Unless every section of the operative report (in particular, the procedure notes) is read, the coder may end up billing 44140, when the correct code is 44160. Furthermore, both the surgeon and coder may be unaware that there are other partial colectomy codes that more closely approximate the actual procedure performed.
 
Therefore, before such a procedure is billed, several important pieces of information need to be obtained from the operative report, Callaway says, including:
 

What section of the colon was removed?
 

How was the colectomy repaired?
 

Was a colostomy created?
 

How close was the removed section of colon to other organs or other parts of the intestines?  
Of course, to obtain such information from the surgeon's procedure notes requires a working knowledge of the appropriate medical terminology, Callaway notes. She adds that surgeons can help by using CPT terminology whenever possible, especially at the top of the operative report, and more generally by accurately describing what they did.
 
"Surgeons differ in their attention to written detail," Callaway says. "For example, a surgeon may note that a section of colon was removed. Anatomically speaking, the surgeon needs to be very specific about what was performed and where the procedure[s] began and ended. If the coder is obtaining billing information from the operative report, as he or she should be doing, the surgeon is well served by providing a clear op note using CPT terminology ."
 
Coders should also consult with surgeons if they do not know which code best describes the procedure performed.
 
Because 44140 has slightly more relative value units (32.57) than 44160 (31.48), this particular coding error would not result in any significant reimbursement loss. But it remains a classification error -- as physicians are expected to code to the highest level of specificity -- and could be questioned later if an audit is performed."