General Surgery Coding Alert

Don’t lose pay for additional resections.

When you face your general surgeon’s op report for a small intestine resection, do you have the coding savvy to sort it out?

Let our experts show you three key questions you’ll need to answer to make sure you pick the right code — and get the right pay — every time.

What is the Surgeon’s Approach?

As with many surgical procedures, the first thing you need to determine from the op report is the surgical approach: in this case, open or laparoscopic.

The answer to that question will lead to at least two different enterectomy codes:

• 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) for an open surgery, or
• 44202 (Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis).

“Both of these procedures involve the surgeon removing a portion of the small intestine and re-attaching the resulting proximal and distal portions,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. “The difference is the surgical approach.”

Where in the Intestine Does the Resection Occur?

The surgical report should include some documentation that the resection involves the small intestine. The surgeon might name a specific section, such as duodenum, or simply locate the section of small intestine by indicating a measurement. See “Decode Small Intestine Resections With These Terms” on page 66 for a glossary to help interpret your op report. 

Multiple resections: Look for evidence in the op report that your surgeon removed an additional small intestine portion and performed another anastomosis in the same operative session. If that’s the case, you’ll need to report one of the following 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]).

“These are add-on codes, so you’ll need to match it with the primary procedure code: Use +44121 with 44120 and +44203 with 44202,” Bucknam says.

Watch for enterostomy: If the surgical report for an open enterectomy indicates that the surgeon also performed an enterostomy, you’ll need to use a different code. In that case, select 44125 (Enterectomy, resection of small intestine; with enterostomy) rather than 44120.

Why Did the Surgeon Resect Intestine?

If the surgeon performs an enterectomy to correct congenital intestinal atresia (751.1, Congenital atresia and stenosis of small intestine), forget everything you just read.

That’s because CPT® provides distinct codes for such a procedure. Instead of 44120-+44121 or 44202-+44203, you should use the following code(s) as appropriate:

• 44126 — Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; without tapering
• 44127 — ... with tapering
• +44128 — ... each additional resection and anastomosis (list separately in addition to code for primary procedure).

Choose between 44126 or 44127 based on whether the surgeon tapers the bowel. “You might see terms like ‘retrofit’ or terms that describe diminishing the distal or proximal anastomosis site to indicate that the surgeon tapered the intestine,” Bucknam says.

Like the other enterectomy codes, you’ll use the add-on code if the op report shows evidence of multiple resections in the same operative session.