General Surgery Coding Alert

You risk losing out on your rightful reimbursement if you limit yourself to CPT's partial colectomy codes when none of them apply, especially for colon resections that include other procedures.

When surgeons resect a patient's colon, the procedure is typically billed as a partial colectomy. Depending on the circumstances, the remaining colon sections may not be anastomosed (reattached). Instead, the surgeon creates a colostomy and, in some cases, closes the colon's distal segment by performing a Hartmann-type procedure.

CPT has a variety of partial colectomy codes that include several additional procedures, such as anastomosis, colostomy creation, Hartmann-type distal end closure, and removal of terminal ileum. In some cases, none of these codes apply, although many coders may inadvertently choose them because they automatically look to CPT's partial colectomy section when a colon is resected.

A Case Study

According to the following procedure notes, the surgeon removed a fistula connecting the bladder and the colon, resected part of the colon and created a temporary colostomy, says M. Trayser Dunaway, MD, a general surgeon in private practice in Camden, S.C. The physician refers to a Hartmann procedure (to close the remaining distal colon) at the beginning of the operative report but does not describe it in the procedure notes:

Pre- and post-op diagnosis: vesicocolonic fistula secondary to acute diverticulitis. A urologist inserted a urethral catheter The abdominal cavity was entered through a previous incision. Massive adhesions from previous surgery were found so lysis of adhesions was performed. Then the pelvic area was reached; it was friable and easily bleeding. The upper sigmoid seemed to be attached firmly to the bladder with an inflammatory process.

""The proximal sigmoid descending colon was divided then the rest of the inflamed colon was followed down in the pelvis. A portion of healthy rectum was found and the large bowel was transected above the peritoneal reflection.

""Then the inflamed colon was detached from bladder the opening which was closed in two layers. The abdominal cavity then was irrigated with copious amounts of normal saline all bleeding was controlled the descending colon was brought in to the left lower portion and a temporary colostomy was performed through a button-hole incision in the skin that split the muscle.""

Don't Trust Your Instincts

Because the colon was resected many coders may wish to report 44141 (Colectomy partial; with skin level cecostomy or colostomy) or 44143 ( with end colostomy and closure of distal segment [Hartmann type procedure]). But neither code is correct because they do not accurately describe the bladder repair or the fistula removal.

Note: You should not report 44143 in any event because the surgeon notes the Hartmann procedure only at the beginning of the operative report not in the procedure notes.

The correct codes for this scenario are 44661 (Closure of enterovesical fistula; with intestine or bladder resection) and 44320 (Colostomy or skin level cecostomy [separate procedure]).

The primary diagnosis code associated with 44661 is 596.1 (Intestinovesical fistula). Report ICD-9 code 562.11 (Diverticulitis of colon [without mention of hemorrhage]) as the secondary diagnosis.

Note: Code 44320's status as a separate procedure does not prevent it from being reported in this case because that status applies only when it is performed at the same time as another colostomy or cecostomy.

We can assume the surgeon performed the bladder repair because the note describes it says Elaine Elliott CPC a general surgery coding and reimbursement specialist in Jensen Beach Fla. The urologist likely participated in the session to position the ureteral catheters near the ureters where urine drains from kidney to bladder to avoid inadvertent damage during the procedure she adds.

The urologist typically uses cystoscopy to place these catheters which must be moved through the bladder to be positioned at the ureters Elliott says. Occasionally a general surgeon may also place these catheters also called stents.

Had the surgeon better documented the amount of additional effort risk and time in the ""massive"" adhesions the notes mention you may have been able to append modifier -22 (Unusual procedural services) to 44661 Elliott says. But because the documentation in this case does not support the additional reimbursement you should not bill the adhesions.