General Surgery Coding Alert

When a physician closes a colostomy, resection and anastomosis of the bowel may or may not be performed. Resection and anastomosis often accompany a closure. If the surgeon doesnt indicate that the resection was performed, coders should request the pathology report, if one is pending, before billing the procedure, as there is a large (almost five relative value units [RVUs]) difference between a simple colostomy closure and one involving resection and anastomosis.

Better yet, the surgeon should describe any resection and anastomosis performed with a colostomy closure during the same operative session by noting in the operative note, for example, takedown of colostomy with bowel resection and anastomosis. This will eliminate any possible confusion for the coder. Further, the location of the resection should be documented because resections performed in the colorectal area are reimbursed substantially higher than those performed in other sections of the bowel.

Colostomies sometimes are performed on patients with diverticulitis or an abdominal abscess. They also may be performed on cancer patients who have had colon resections to protect the area of anastomosis. The colostomy diverts the stool, which allows the wound to heal better and more safely.

Coding a Closure

Weeks or months after the initial procedure, the surgeon may decide to close the colostomy; often, a resection and anastomosis of the bowel also is performed. Depending on what the surgeon performed, the following codes may apply:

44620 closure of enterostomy, large or small intestine (16.38 RVUs); and

44625 with resection and anastomosis other than colorectal (21.14 RVUs); and

44626 with resection and colorectal anastomosis (e.g., closure of Hartmann type procedure) (34.71 RVUs).

If the colostomy is closed and no resection is performed, 44620 is used to code the procedure, which involves taking down the stoma of the colon and sewing it back together.

For example, a patient with colon cancer has a coloproctostomy with colostomy (44146, colectomy, partial; with coloproctostomy [low pelvic anastomosis], with colostomy). Three months later, the surgeon closes the colostomy. No resection is performed. This procedure would be coded 44620 because the surgeon did not remove any tissue, although anastomosis was performed to reconnect the opened section of colon that formed the colostomy.

Sometimes, however, resections are performed when colostomies are closed. The surgeon may locate an obstructing abdominal mass or lesion but decide to perform a colostomy to allow the dilated colon to resolve and only perform the resection (colectomy) when the colon has settled down.

If the resection is performed anywhere but the colorectal area (the sigmoid colon, for instance), the procedure would be coded 44625. If the colon is resected in the colorectal area (which is more difficult because the mass is in a deeper area that requires a different approach), the procedure should be coded 44626.

Of course, the fact that a resection was performed at all, and that the section of colon was resected, needs to be documented in the operative report, says Elaine Elliott, CPC, a practice coder with Treasure Coast Surgical Group, a seven-physician practice in Stuart, Fla.

Because resections of the colostomy site are performed more often than not, if no resection was documented, you should wait to see if the pathology report documents that a resection was performed, Elliott says. This will result in higher reimbursement.

Unfortunately, some surgeons simply note colostomy closure at the top of the operative report, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. If the coder doesnt read the procedure notes in the report, or if the surgeon doesnt elaborate further in those notes and the claim is sent out before a pathology report is sent back to the surgeons office, only 44620 may be coded, Mueller says.

When a Colectomy Is Separately Billable

Normally, the reimbursement for the colectomy (resection) performed during the closure of a colostomy is included in the colostomy payment. But in some situations, a separate colon resection (i.e., 44145, colectomy, partial; with coloproctostomy [low pelvic anastomosis]) also is performed during the same session when a colostomy is being closed.

For example, the surgeon sees a patient with severe abdominal pain, a history of diverticulosis and rebound tenderness. The surgeon performs an exploratory laparotomy of the abdomen and identifies severe diverticulitis, in this case, a large abscess in the sigmoid colon. The decision not to resect the sigmoid and instead perform a transverse loop colostomy (44320, colostomy or skin-level cecostomy; [separate procedure]) is made. In addition, the peritoneal abscess is drained (49020, drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open).

At a later date, when the inflammation and infection have resolved, a sigmoid colectomy with primary anastomosis (44145) is performed. The original loop colostomy also is closed and may be billed separately. Because, under normal circumstances, the 44620 is bundled to the colectomy (44145), modifier -59 (distinct procedural service) should be appended to the 44620 to indicate that the closure of the original loop colostomy has occurred at a different site (e.g., transverse colon) than the partial colectomy of the sigmoid colon, Mueller says.

If the resection occurs within the global period of the loop colostomy, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be added to code 44145, Elliott adds.