General Surgery Coding Alert

Question: How should a laparotomy with irrigation of stool and formation of ileostomy with mucous fistula be coded? The surgeon performed a partial resection because the previous anastomosis came apart and spilled feces into the peritoneal cavity. The diagnosis was dehiscence of previous small bowel to colon anastomosis.

Delaware Subscriber

Answer: Without an operative report, this procedure is difficult to code accurately. The failed anastomosis of the small bowel to colon was removed at the second operation, however, so the resection may be described as a kind of partial colectomy. The proximal active limb of the ileum digestive tract is formed into an ileostomy, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. The distal inactive stump of colon also is brought up to the skin, most often through the fascial incision of the second procedure, and is referred to as a mucous fistula.

Accordingly, the correct code for this procedure is 44144 (colectomy, partial, with resection, with colostomy or ileostomy and creation of mucofistula), says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. If this procedure is performed within the (90-day) global period of the original service, modifier -78 (return to the operating room for a related procedure during the postoperative period) should be appended to 44144. The correct ICD-9 code would be 997.4 (digestive system complications).

The exploratory laparotomy (49000) is bundled to 44144, as is the irrigation of stool in the peritoneal cavity (49080), so neither code should be billed. Mueller notes, however, if the 44144 is performed within 90 days of the original procedure, 49002 (reopening of recent laparotomy) may be billed, with modifier -78 attached.