General Surgery Coding Alert

Question: Operative notes indicate that the surgeon performed a colonoscopy through a created stoma. Is there a specific CPT code that I should use for this particular procedure?

Answer: You have several codes to choose from when the surgeon performs a colonoscopy via artificial stoma.

Go back to the op note to get some supporting details to help you select the proper code. For instance, did the surgeon perform a biopsy, take out a foreign body, or remove a lesion with a specific technique during the colonoscopy? You should also find out whether the stoma was a colostomy (which opens into the colon) or ileostomy (which opens into the small intestine).

Example: The operative note indicates a colonoscopy via colostomy with no mention of biopsy or lesion removal. In that case, report 44388 (Colonoscopy through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the encounter. Review the definitions of CPT codes 44380 through 44394 to familiarize yourself with the different types of stoma-related procedures and choose the appropriate code based on your surgeon's notes.

-- Reader Questions and You Be the Coder were prepared with the assistance of Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.