General Surgery Coding Alert

Question: Gallstone identified in med-jejunum causing bowel obstruction. Surgeon performed midline laparotomy and enterotomy, allowing removal of the gallstone. Finding edematous tissue in the small bowel distal to the obstruction, the surgeon performed a partial enterectomy and completed a functional end-to-end anastomosis to the enterotomy site. The op note states 44130 -- is that the correct code for this procedure?

Arizona Subscriber

Answer: Although part of the procedure would be described by 44130 (Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy [separate procedure]), that is probably not the best 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 list a more comprehensive code that captures the enterectomy as well as the anastomosis of the resected bowel to the enterotomy site. The more descriptive code would be 44120 (Enterectomy, resection of small intestine; single resection and anastomosis).

Beyond intention: Although the surgeon's original intent may have been to perform a 44130 service to remove the gallstone, the findings during the procedure prompted additional work. Because of the observed edematous bowel tissue, the surgeon went on to remove a section of small bowel. You need to ensure that your coding reflects the work documented in the op note, not just the procedure code that might be listed at the top of the note based on the planned procedure.