General Surgery Coding Alert

Reporting resections of the small intestine differs considerably from reporting the more familiar colectomy procedures. In just three steps, however, you can claim the correct small-bowel enterectomy code without fail.

For simple resection of the small intestine, you must first determine if the surgeon used an open or laparoscopic approach. In either case, this type of enterectomy involves removing one or more portions of the small intestine (excision or resection), with re-attachment of the resulting proximal and distal portions of the intestine (anastomosis).

Dx watch: "I-d say the most common reason I-ve done small-bowel resections is for ischemia caused by obstructions, such as in a small-bowel obstruction from bands or hernias," says M. Tray Dunaway, MD, FACS, CSP, a general surgeon and an educator with Healthcare Value Inc. in Camden, S.C. Other indications include ulcerative colitis (556.x), ischemic bowel disease/vascular insufficiency of the intestine (557.x), and trauma.

For excision of a single section of small intestine, you would report either 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) for an open approach or 44202 (Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis) for a laparoscopic approach, says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla.

For any resection beyond the first during the same operative session, you would report add-on codes +44121 (Enterectomy, resection of small intestine; each additional resection and anastomosis [list separately in addition to code for primary procedure]) for an open procedure or +44203 (Laparoscopy, surgical; each additional small intestine resection and anastomosis [list separately in addition to code for primary procedure]), Martien says.

You must report 44121 only in addition to 44120, and 44203 only in addition to 44202. You may report one unit of 44121 or 44203, as appropriate, for each resection beyond the first.

Example: Using a laparoscope, the surgeon removes three separate portions of a patient's small intestine. You would report 44202 for removal and anastomosis of the first portion of the small intestine, plus 44203 x 2 for removal and anastomosis of each additional portion.

Take note: If the surgeon begins the procedure with the endoscope but must convert to an open enterectomy to complete the procedure, you should report the open codes only, with ICD-9 code V64.41 (Closed surgical procedure converted to open procedure; laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis, Martien says.

When reporting an open enterectomy (44120), keep an eye on the operative report for evidence that the surgeon performed an enterostomy.

During enterostomy, the surgeon makes a hole into the patient's small intestine to create a side opening for an anastomosis, bring out a stoma, or even to insert a feeding tube, Dunaway says.

For enterectomy with enterostomy, you would select 44125 (Enterectomy, resection of small intestine; with enterostomy) rather than 44120.

In those rare instances when the surgeon performs enterectomy for the specific purpose of correcting congenital intestinal atresia (751.1, Atresia and stenosis of small intestine), you should look to 44126-44128.

Atresia describes a failure of a portion of the intestinal tract to form completely. To treat the problem, the surgeon removes the unformed portion of the intestine and anastomosis the resulting ends together, Martien says.

For the initial resection, select either 44126 (Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; without tapering) or 44127 (... with tapering), depending on whether the surgeon tapers the bowel to improve function and transit times.

"Terms that could clue you in that the surgeon performed tapering include -retrofit/retrofitted/retrofitting,- or terms that describe diminishing or lessening of either the distal or proximal anastomosis site," Martien says.

For any intestinal resections beyond the first, call on add-on code +44128 (... each additional resection and anastomosis [list separately in addition to code for primary procedure]).