General Surgery Coding Alert

"There are several CPT codes for partial colectomy procedures, and selecting the right one depends on the type of procedure performed and the location of the section of colon that was removed.

For example, a partial colectomy may involve colostomy or anastomosis (joining two tubular structures together). Before billing for such a procedure, the coder needs to know:

what section of the colon was removed;
how extensive was the disease that led to the colectomy; and
how was it repaired and was an outlet to outside the body created.

Other factors to consider include the extent of the disease and proximity of the removed section of colon to other organs or other parts of the intestines, says Susan Callaway-Stradley, CPC, a coding specialist with the Medical Group of Elliott, Davis & Co., an accounting and consulting firm specializing in Medicare, based in Augusta, GA.

Coding staff in the surgeons office should consult with the physician if they are uncertain about which code to bill. Usually, if Im not really sure which portion of the colon was removed, I ask the physician to look at the codes and see which one best describes the procedure, because they are hard to figure out, says Denise Stokes, a coder with Carolina Physicians in Greenville, NC. The physician will look at them and tell me which code is closest to the procedure he or she performed.

To correctly bill partial colectomies, coders need to understand the anatomy and term definitions associated with the procedures, says Susan L. Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, WI, and the representative to the AMA CPT Advisory Committee for the American Medical Group Association.

Coders need to understand the difference between an ostomy (opening to outside), ectomy (resection, take out a part), and anastomosis (connecting the parts), says Turney, adding that surgeons, for their part, need to make sure they are clear in their documentation on:

what part of the colon was actually removed;
which sections of the colon were actually
anastomosed, or brought together; and
whether there are any new openings to the outside for drainage.

Some surgeons are more detailed than others, Turney explains. A surgeon might simply report that he or she has removed the colon and connected the ileum to the rectum. The surgeon, however, may also have taken out part of the rectum, but didnt indicate that in the chart.

Turney says the surgeon needs to be explicit, anatomically speaking, about where the procedure began and ended. The burden is on the physician to make sure the description of the procedure is correct. If the surgeons office staff is extracting information from the operative report on the partial colectomy, its in the surgeons best interest to provide a clear and accurate description.

There are seven codes grouped together in CPT 1999 that specifically describe partial colectomies (44140-44147). In addition, code 44160 also describes partial colectomies performed in conjunction with another procedure.

The first code, 44140 (colectomy, partial; with anastomosis), is used when the physician resects a segment of colon and performs an anastomosis between the remaining ends of the colon. The surgeon makes an abdominal incision, isolates the selected segment of colon and divides it proximally and distally to the remaining colon and removes it. The remaining ends of the colon are stitched together using either staples or sutures, and the incision is closed.

Code 44141 (colectomy, partial; with skin level cecostomy or colostomy), is used when the physician removes a segment of colon, makes a separate incision and brings the proximal end of the colon onto the skin as a colostomy.

Alternatively, the remaining bowel ends may be reapproximated and a loop of colon proximal to the anastomosis brought through a separate incision on the abdominal wall onto the skin as a loop colostomy. The initial incision is then closed.

Note: Whether the procedure is a cecostomy or colostomy depends on which part of the colon has been removed.

Code 44143 (colectomy, partial; with end colostomy and closure of distal segment [Hartmann type procedure]) describes when a physician resects a segment of colon and brings the proximal end of the colon through the abdominal wall onto the skin as a colostomy. The distal end of colon is closed with staples or sutures and left in the abdomen, and then the initial incision is closed. After this procedure, the patient will no longer use the portion of the colon below the colostomy, so it is sewn up, leaving a pouch that will never be used again.

Code 44144 (colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula) is used when the surgeon performs a resection and colostomy or ileostomy and creates a mucofistula for the colon, which is no longer used for bowel function but still requires an opening for drainage.

Code 44145 (colectomy, partial; with coloproctostomy [low pelvic anastomosis]) describes when the physician resects a segment of distal colon or rectum and performs a low colorectal anastomosis in the pelvis between the proximal colon and remaining rectum in the pelvis with either staples or sutures.

Note: Code 44145 claims are well reimbursed because low anterior resections are difficult due to the confined working space in the pelvis.

Code 44146 (colectomy, partial; with coloproctostomy [low pelvic anastomosis], with colostomy) is used when a colostomy is added to a 44145 procedure.

Code 44147 (colectomy, partial; abdominal and transanal approach) describes when the physician removes a segment of colon and rectum through a combined abdominal and perineal approach with a proximal colostomy or colo-anal anastomosis. If the physician is working in the sigmoid area, he or she may use an anal approach alone or together with the abdominal approach.

Additional Colectomy Codes

In addition to the seven basic partial colectomy codes described above, two others may be used in certain circumstances.

Code 44160 (colectomy with removal of terminal ileum and ileocolostomy) should be used when the physician removes a segment of the colon and terminal ileum and performs an anastomosis between the remaining ileum and colon.

Code 44139 (mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]) is used when the physician mobilizes the splenic flexure in conjunction with a partial colon resection. The physician dissects the attachments between the splenic flexure of the colon and the lateral abdominal wall free and takes them down to mobilize adequate length of colon in conjunction with a partial colon resection. This code should be billed in conjunction with codes 44140-44147, but should not be added to 44160, since that involves the right side of the colon.

Note: The surgeon does not necessarily have to free the splenic structure when performing a colectomy. Code 44139 is used only when working on the left side of the colon. When using 44139, the surgeon should indicate the freeing of the splenic structure at the top of the note so it is very visible. "