General Surgery Coding Alert

Question:The patient had an exploratory lapartomy with extensive lysis of adhesions, subtotal colectomy, and repair of serosal tear on small bowel. The surgeon removed the transverse colon, cecum, and ascending colon, but due to the patient’s hypertension and multiple ischemic areas on small bowel, he decided to leave the patient in discontinuity, loosely approximating the fascia and placing dressing. Two days later, the surgeon returned the patient to the OR and performed an exploratory laparotomy, abdominal washout, small bowel resection, and ileocolosotmy. How should we report these two procedures?

California Subscriber

Answer: Payers may vary significantly in what charges they’ll accept for this case, but for commercial payers, the following coding best represents the services provided:

44140-52 -- Colectomy, partial; with anastomosis(Reduced services). Use modifier 52 because there is no mention of anastomosis.

44005-59 -- Enterolysis (freeing of intestinal adhesion) (separate procedure) (Distinct procedural service). You can’t bill this to Medicare.

44602 -- Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation. Make sure your documentation shows that the serosal damage was due to the adhesions and not to surgical error.

Caution: You’ll need to ensure good documentation and make sure you follow payer rules for this case. If Medicare is the payer, you won’t be able to collect separately for the lysis of adhesions, no matter how extensive. Typically you could add a modifier 22 (Increased procedural services) to 44140for Medicare or payers that won’t accept 44005 with 44140. But the only way to code the partial colectomy without anastomosis is to add modifier 52. It just doesn’t make sense to add modifiers 22 and 52 to the same CPT^® code.

Second procedure: You should report 44120-58 (Enterectomy, resection of small intestine; single resection and anastomosis) (Staged or related procedure or service by the same provider during the postoperative period) for the procedure that your surgeon performs two days later.

The washout is always bundled, so there’s no extra charge for that service. However, if the surgeon documents extensive exploration and washout work, it may be possible to add modifier 22.