Omental Pedicle Flaps
Recognize the procedure, learn about it, and code it right.
It isn’t uncommon for one or two lines to be buried within an abdominal surgery operative report documenting a procedure involving the patient’s omentum. The most common of these is the omental pedicle flap—a simple procedure that can be easily recognized, and correctly billed … if you know what to look for.
An omental pedicle flap is performed for two primary purposes:
- To exclude the small bowel from the pelvis; and
- To repair an intra-abdominal defect.
- Clinical indications for the flap include:
- Preventing damage to the small bowel when there is the potential for radiation to the pelvis;
- Repairing an enterocele; and
- Filling pelvic dead space resulting from a colovaginal or colovesical fistula repair.
An omental pedicle flap is fashioned when the physician dissects a portion of the omentum from over the transverse colon. The freed portion of omentum is then rotated (leaving the main blood supply intact), placed into the pelvis to exclude to the small bowel or fill an intra-abdominal defect, and then sutured to the pelvic sidewall and/or organ(s).
The procedural documentation should include the dissection, placement, and suturing of the omentum into the pelvis. When the procedure is identified, the indication will determine the correct CPT® code to bill.
CPT® defines 44700 as an “Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (e.g., bladder or omentum).” A parenthetical note directs the coder to the Radiation Oncology section of CPT® for therapeutic radiation. This guidance suggests that 44700 is linked to radiation therapy.
CPT® 44700 is commonly billed with ICD-9-CM codes for a malignant neoplasm located in the lower abdomen, pelvic, or genital organs. On the other hand, preoperatively a surgeon may not be able to precisely stage a neoplasm, or even predict the final pathological diagnosis (malignant or benign), and radiation therapy is determined by an oncologist postoperatively.
A negative side effect of pelvic radiotherapy is permanent damage to the small bowel mucosa. If a surgeon suspects a patient may undergo radiation therapy, an omental pedicle flap is performed to reduce radiotherapy mucosal damage.
Example A is a portion of a well-documented omental pedicle flap involving a patient primarily undergoing a partial colectomy, Hartmann type, for a rectal neoplasm. In this example, a coder would bill 44700. The detailed operative report selection includes the supporting indication in the first sentence.
Because there is a potential for malignancy, the tongue of the omentum was taken off the transverse colon and mobilized in standard right to left fashion using the LigaSure Impact™ device. This healthy piece of well-vascularized tissue placed deep in the pelvis and secured there with interrupted 3-0 Vicryl sutures to exclude the small bowel from the pelvis in the event that the patient requires adjuvant radiation therapy.
Add-on code 49905 Omental flap, intra-abdominal (List separately in addition to code for primary procedure) is reported when an omental pedicle flap is created and positioned to fill or correct an intra-abdominal defect, such as an enterocele or “dead space,” resulting from a colovaginal or colovesical repair.
Note that CPT® lists another code, 57270 Repair of enterocele, abdominal approach (separate procedure). This procedure involves suturing structures that already exist in the pelvis, such as the uterosacral ligaments and endopelvic fascia anterior to the rectum. This does not involve developing and securing an omental pedicle flap. Many colorectal surgeons recognize the omental pedicle flap as the more successful technique for enterocele repairs.
Example B presents an example of a well-documented omental pedicle flap involving a patient undergoing a primary enterovaginal fistula repair. This documentation supports the use of 49905.
The omentum had been mobilized. It was brought down into the pelvis between the vagina and the rectum and secured with interrupted 3-0 Vicryl sutures to avoid recurrent fistula formation at the level of the anastomosis.
Examples C and D show documentation snippets involving patients with primary resections and include a repair of an enterocele. The documentation in both reports also support the use of 49905.
The enterocele was repaired by taking the tongue of the omentum off the transverse colon, placing it deep within the pelvis, and securing it with interrupted 3-0 Vicryl sutures to exclude the small bowel and fill the enterocele space.
… with the large enterocele, the small bowel was left out of the pelvis and omental flap was created off the transverse colon using a combination of electrocautery and LigaSure Impact™. The omental flap was then seated down into the pelvis and secured there with interrupted 3-0 Vicryl sutures, such that the small bowel could not enter the pelvis.
Look out for Laparoscopic Procedures
Both 49905 and 44700 are open surgical codes. If a physician performs a laparoscopic or robotic omental pedicle flap, the coder replaces 44700 with unlisted code 44238 Unlisted laparoscopy procedure, intestine (except rectum), and replaces 49905 with 49329 Unlisted laparoscopy procedure abdomen, peritoneum and omentum.
Spending five minutes with a physician to discuss the appropriate CPT® codes, as well as giving examples of proper code documentation, is well worth the time.
The most successful documentation discussions I have with physicians include reminding them that they are no longer just documenting what happened during a procedure; they are documenting to get paid. Physicians should document each procedure in a separate paragraph, state the indication, and use simplistic sentence structure. This reinforces medically necessity and cuts down on denials.
I also discuss the relative value units (RVUs) and reimbursements for each code, and remind the physician that add-on codes do not follow the reduction rule for secondary and tertiary procedures. Missed or denied reimbursement for these codes will adversely affect a practice’s bottom line.
Omental pedicle flaps’ history for denials varies, mostly as a result of unlisted code billing.
An unlisted code requires submission of supporting documentation, such as the operative report. Physicians and coders should recognize that the insurance company employee reviewing the first level appeal is not the medical director. Usually a nurse, medical assistant, or coder without extensive knowledge of your specialty is conducting the review. For this reason, appeal letters and accompanying documentation need to be clear and concise.
Appeal cover letters are often as important as the operative report because they provide the physician or coder with an opportunity to expound on the physician’s medical decision-making process, and to supply additional authoritative documents or articles. The example below shows an extract of an omental pedicle flap appeal letter.
Many rectal cancers do not require an exclusion of small bowel from pelvis (44700 Exclusion of the small bowel from the pelvis). However, in mid to low rectal cancers, patients often require postoperative external beam radiation therapy. Because the physician cannot precisely stage the rectal cancer preoperatively, he or she excludes the small bowel from the pelvis to protect the small bowel from significant damage from radiation therapy. It is standard of care to exclude the small bowel in this type of rectal cancer.
Unlisted CPT® 44238 represents a laparoscopic exclusion of small bowel from pelvis with an omental pedicle flap. The equivalent open code is CPT® 44700. Currently, CPT® does not include a specific code to describe the laparoscopic version of this procedure.
The small bowel is excluded from the pelvis using an omental pedicle flap to prevent permanent small bowel mucosal damage from radiation therapy for the cancerous lesion. Because the physician cannot precisely stage the rectal cancer preoperatively, he excludes the small bowel from the pelvis (44238) in patients with rectal cancer in anticipation of radiotherapy, in addition to the primary left colectomy (44207 Laparoscopic partial colectomy with low pelvic anastomosis) that removes the lesion. CPT® 44207 does not include reimbursement for the additional omental pedicle flap.
Reimbursement for the left colectomy is for that procedure only. For example, if a patient has a left colectomy (44207) for diverticulitis, the physician would not create an omental pedicle flap to exclude the small bowel because there would be no possibility of radiation therapy. Reimbursement for the left colectomy is for that procedure only.
Please reconsider this claim for additional payment of CPT® 44238. Clearly, this is not inclusive to procedure 44207. Dr. Doolittle should be compensated accordingly for the additional procedure.
When you know what to look for, the omental pedicle flap is one of the more easily identified procedures within an operative report. A simple investigation of the flap indications assists the coder in determining the correct CPT® choice. You can ensure your physician is appropriately paid for his or her work by educating physicians on documentation requirements, and by following up on denials with well-written appeals.
Anna Conlon Barnes, CPC, CEMC, CGSCS, is the director of operations for Atlanta Colon and Rectal Surgery. Her duties include overseeing corporate compliance programs, physician auditing and education, and director of information technology, as well as managing billing department activities, including staff coding compliance and education. She holds a BSED from the University of Georgia, and has 17 years of management experience in colon and rectal surgery.