General Surgery Coding Alert

Question: A gallstone was found in the middle part of the small intestine, leading to a blockage. The surgeon carried out a midline laparotomy and enterotomy to remove the gallstone. The surgeon noticed swollen tissue in the small intestine beyond the blockage point, so a partial enterectomy was performed. The surgeon then completed a functional end-to-end anastomosis at the enterotomy site. Should I use 44130 or 44120 for this procedure?

West Virginia Subscriber

Answer: Although part of the procedure would be described by code 44130 (Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separate procedure)), that is not the most accurate code choice for the entire encounter. Code 44130 describes the enteroenterostomy, but misses the work involved in resecting a section of small bowel.

Instead, you should use a more inclusive code that covers both the enterectomy and the reconnection of the removed bowel section to the enterotomy site. The more descriptive code would be 44120 (Enterectomy, resection of small intestine; single resection and anastomosis).

Coding note: While the surgeon may have initially planned to carry out a 44130 procedure to extract the gallstone, the circumstances during the operation necessitated further action. Due to the discovery of swollen tissue in the small intestine, the surgeon proceeded to remove a segment of the small bowel. It’s crucial that your coding accurately represents the operations detailed in the surgical report, rather than solely relying on the procedure code that may be mentioned at the beginning of the report based on the initially intended procedure.