Physician Documentation is Critical When Coding Partial Colectomies
Published on Sun Aug 01, 1999
"There are several CPT codes for partial colectomy procedures, and selecting the right one depends on the type of procedure performed and the location of the section of colon that was removed.
For example, a partial colectomy may involve colostomy or anastomosis (joining two tubular structures together). Before billing for such a procedure, the coder needs to know:
what section of the colon was removed;
how extensive was the disease that led to the colectomy; and
how was it repaired and was an outlet to outside the body created.
Other factors to consider include the extent of the disease and proximity of the removed section of colon to other organs or other parts of the intestines, says Susan Callaway-Stradley, CPC, a coding specialist with the Medical Group of Elliott, Davis & Co., an accounting and consulting firm specializing in Medicare, based in Augusta, GA.
Coding staff in the surgeons office should consult with the physician if they are uncertain about which code to bill. Usually, if Im not really sure which portion of the colon was removed, I ask the physician to look at the codes and see which one best describes the procedure, because they are hard to figure out, says Denise Stokes, a coder with Carolina Physicians in Greenville, NC. The physician will look at them and tell me which code is closest to the procedure he or she performed.
To correctly bill partial colectomies, coders need to understand the anatomy and term definitions associated with the procedures, says Susan L. Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, WI, and the representative to the AMA CPT Advisory Committee for the American Medical Group Association.
Coders need to understand the difference between an ostomy (opening to outside), ectomy (resection, take out a part), and anastomosis (connecting the parts), says Turney, adding that surgeons, for their part, need to make sure they are clear in their documentation on:
what part of the colon was actually removed;
which sections of the colon were actually
anastomosed, or brought together; and
whether there are any new openings to the outside for drainage.
Some surgeons are more detailed than others, Turney explains. A surgeon might simply report that he or she has removed the colon and connected the ileum to the rectum. The surgeon, however, may also have taken out part of the rectum, but didnt indicate that in the chart.
Turney says the surgeon needs to be explicit, anatomically speaking, about where the procedure began and ended. The burden is on the physician to make sure the description of the procedure is correct. If the surgeons office staff is extracting information from the operative report on the partial colectomy, its in the [...]
