General Surgery Coding Alert

Not all partial colectomy procedures are created equal, and close attention to the op report's details could uncover hidden reimbursement opportunities. Here are six tips on what you-ll want to be watching for.

To report a partial colectomy, you should choose either 44140 (Colectomy, partial; with anastomosis) for a simple approach or, for a combined abdominal/transanal approach, 44147 (... abdominal and transanal approach). If the surgeon refers to the transverse colon, chances are she performed a "straight anastomosis" as described by 44140. Regardless of the approach, the surgeon will remove the diseased section of colon and reattach the distal and proximal ends of the remaining colon.

Know your terms: The surgeon won't typically dictate "partial colectomy" in the op note, says M. Trayser Dunaway, MD, a surgeon, speaker, coding educator and healthcare consultant in Camden, S.C. Instead, the surgeon will typically write "right hemicolectomy," "left hemicolectomy," "sigmoidectomy," or "subtotal colectomy."

2. Look for Coloproctostomy First

When reviewing a colectomy op report, you should first determine whether the surgeon performed a coloproctostomy, or low pelvic resection and anastomosis. For coloproctostomy with partial colectomy, report 44145 (... with coloproctostomy [low pelvic anastomosis]).

Next, scan the op note for evidence of a colostomy, which the surgeon often performs to divert the fecal stream away from the site of the anastomosis or even the entire distal colon and thus facilitate healing.

The surgeon may perform the colostomy using one of several methods, says Terri Brame, CPC, CPC-H, principal at BEST Coders. During the more typical "loop" colostomy (44141, ... with skin-level cecostomy or colostomy), the surgeon will open only part of the colon wall without complete resection of the colon. A Hartmann procedure, or "end" colostomy (44143, ... with end colostomy and closure of distal segment [Hartmann type procedure]), involves bringing the proximal end of the colon to the skin surface as a stoma.

Along with an 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).

All-in-one special: If the surgeon performs both coloproctostomy and colostomy, along with partial colectomy, you should use 44146 (... with coloproct-ostomy [low pelvic anastomosis], with colostomy).

During right hemicolectomy, the surgeon typically removes the terminal ileum when reconnecting the ileum to the distal remaining colon because the blood flow to the cecum isn't good enough to make a cecum-colonic anastomosis, Dunaway says. In these cases, you should report an ileocolostomy (44160, Colectomy, partial, with removal of terminal ileum with ileocolostomy) rather than a standard partial colectomy, 44140.

Remember: Ileostomy with mucofistula calls for code 44144.

Especially when reporting a left partial colectomy, you should look for evidence that the surgeon freed, or mobilized, the splenic flexure (the portion of the colon that links the transverse and descending colon). The surgeon will perform this procedure because there isn't enough slack in the remaining colon to reconnect the two ends without tension.

To report mobilization of the splenic flexure, you should 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, Brame says.

When reporting colectomy procedures, you should read the entire documentation report rather than choose codes based only on the op report's "header."

For example, the surgeon may say she performed a "standard right hemicolectomy," which typically includes removing the ileum and forming an ileocolostomy. If you don't find evidence for the ileum removal and ileocolostomy by reading the op report, however, you could easily choose 44140 rather than the correct code, 44160.

Tip: Pathology reports will help clarify exactly what portion of anatomy the surgeon removed.