General Surgery Coding Alert

Plus: Watch for unlisted service you can't afford to miss.

Challenge yourself with this real-life complex fistula surgery to see if you can pinpoint the codes this documentation does -- and doesn't -- back up.

Begin by Analyzing the Report Excerpt

The preliminary report states:

Preoperative Diagnosis: Crohn's disease.

Procedure Performed: Laparoscopic-assisted right hemicolectomy and fistulae take-down.

Procedure Description: The surgeon established pneumoperitoneum and inserted the camera through a 10mm infraumbilical incision, identifying a ileocolic phlegmon in the right lower quadrant.

The surgeon began by reflecting the small bowel from the pelvis into the upper abdomen, then freeing the terminal ileum from the right pelvic inlet sharply. The cecum was adherent to the anterior abdominal wall, and this was taken down sharply. The surgeon then worked from lateral to medial, taking the cecum and the right colon away from the lateral sidewall up toward the hepatic flexure.

Realizing that the ileocolic phlegmon also involved multiple other loops of small intestine and the proximal transverse colon with multiple fistulas, the surgeon mobilized the hepatic flexure and enlarged the infraumbilical incision to exteriorize the phlegmon so that he could decipher the multiple apparent fistulas and figure out how to best manage them. Loops of ilium and mid-small bowel, as well as proximal transverse colon, were drawn into the cecum, resulting in multiple fistulas.

On the exteriorized phlegmon, the surgeon began by taking down the fistula to the transverse colon. This left a small defect in the transverse colon, which was treated with multiple sutures. Next, the surgeon disconnected one small intestine fistula and closed the defect with simple suture closure. Two other small intestine fistulas were broadly involved and required resection to free them from the phlegmon. The surgeon took the segment between clamps, including the ileocolic valve, and ligated the ends with ties, removing the mass en bloc. The surgeon then resected another similarly involved small bowel segment.

This left three pieces of bowel that required restoration of continuity: the ileocolic anastomosis and two small intestine anastomoses. The surgeon restored ileocolonic continuity by forming a neoterminal ileum to transverse colon anastomosis using a GIA-75 stapler as a common channel.

Extract the Steps

The first thing you should do is go through the report and highlight each procedure the surgeon performed. "Don't code by the general description under the 'procedure performed' heading; you should always code from the detailed description," advises Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. Your list for the laparoscopic-assisted intestinal resection should look something like this:

• Laparoscopic-assisted right hemicolectomy
• Takedown of ileal fistula
• Takedown of ileocolonic fistula
• Repair of small intestine enterotomy at the site of the fistula x 1
• Repair of colotomy at the site of the fistula x 1
• Small intestine resection x 2.

Capture Enterectomies With Add-On

Although the surgeon documents two enterectomies, you won't report any code x 2. Instead, you'll use a parent code and an add-on to capture both small intestine resections.

For laparoscopic-assisted excision of a single section of small intestine, you should report 44202 (Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis), says Linda Martien, CPC, CPC-H, coding and compliance specialist for National Healing Corp. in Mexico, Mo.

For any resection beyond the first during the same operative session, you should report add-on code +44203 (... each additional small intestine resection and anastomosis [list separately in addition to code for primary procedure]), Martien says.

'Exteriorized' still lap: Code 44202 applies regardless of how the surgeon performs the laparoscopic procedure. The surgeon may complete the entire resection within the abdomen, or he may make a small incision to pull the affected section of small intestine out of the body to perform the resection. "Either way, you should report 44202 for the first laparoscopic enterectomy," says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, coding consultant in Lenzburg, Ill.

Watch for Modifier with Colectomy

Report the right hemicolectomy with 44205 (... colectomy, partial, with removal of terminal ileum with ileocolostomy). "Use 44205 instead of 44204 (... colectomy, partial, with anastomosis) to capture the ileocolostomy described in the op note," Bucknam says.

Remember 59: Because the Correct Coding Initiative (CCI) edits bundle 44202 as a column 2 code with 44205, you'll have to append modifier 59 (Distinct procedural service) to 44202 to override the edit pair. "Because the surgeon performs the resections at different parts of the bowel, you can legitimately unbundle 44202 and 44205 in this instance," Bucknam says.

Use Unlisted Code for Lap Fistulae Closure

CPT® provides a code for fistulae closure -- 44650 (Closure of enteroenteric or enterocolic fistula). But you can't use the code for this case, because it's an open code, and this case is a laparoscopic procedure.

"There's no equivalent laparoscopic fistula repair code in CPT®, so you'll need to use the unlisted laparoscopic code 44238 (Unlisted laparoscopy procedure, intestine [except rectum]) instead," Bucknam says.

Although the op report notes four fistulae, only two were separately repaired because the other two were removed with the en block small intestine resection. That means you should report 44238 x 2 and price the codes for 44650 equivalency.

Sum it up: The final coding for this case is as follows:

• 44205
• 44202-59
• +44203
• 44238x2.