The American College of Surgeons (ACS), the American Society of Colon and Rectal Surgeons (ASCRS), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have recently received inquiries about correct Current Procedural Terminology (CPT*) coding for colectomy procedures. It appears that national coder websites and coder discussion boards have been providing incorrect coding guidance, which may represent the root cause of the coding confusion. This column provides information that should clear up the uncertainty about how to correctly code laparoscopic colectomy procedures.
Laparoscopic colectomy description of work
A laparoscopic colectomy is performed with most of the procedure completed intracorporeally, including, but not limited to, a diagnostic laparoscopy, mobilization of the intestine, vascular ligation, and bowel transection. This work is followed by either an extension of a trocar site incision or creation of a separate small incision for extraction of the specimen and/or extracorporeal creation of an anastomosis based on surgeon preference. After an extracorporeal anastomosis, the colon is returned to the abdomen, the extraction site is closed, pneumoperitoneum is reestablished, and the remainder of the procedure is performed laparoscopically, including final irrigation and inspection.
The following clinical example and procedural description was used in the development of the code descriptor and the Medicare physician fee schedule work relative value units for code 44205, Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum and ileocolostomy.
Clinical example: A 27-year-old male patient has had Crohn’s disease (CD) of the terminal ileum for six years. He has been treated with multiple medications but continues to have exacerbations of his disease that are severe enough to require time off of work on a regular basis. The decision is made to proceed with surgery to remove the involved segment of terminal ileum.
Description of procedure: Place trocars through the abdominal wall at the umbilicus, right lower quadrant, and lower midline. Take special care to avoid the epigastric vessels and all intra-abdominal and retroperitoneal structures. An additional port may be necessary depending on patient anatomy. After insufflation with CO2 (carbon dioxide), insert the laparoscope and perform a visual inspection of the abdominal contents. Then mobilize the terminal ileum and ascending colon by incising the lateral peritoneal attachments. Divide the hepatocolic ligament to allow mobilization of the hepatic flexure. Visualize and protect the duodenum and right ureter during this mobilization.
Once the mobilization is complete, remove the trocar in the right lower quadrant and enlarge the incision to allow for delivery of the involved terminal ileum and cecum out of the abdominal cavity. Then divide the terminal ileum 5 cm proximal to the CD with a stapling device. Divide the ascending colon in a similar fashion. Then ligate and divide the ileocolic vessels and any other mesentery to the involved bowel. Hand off the resected specimen from the surgical field. Accomplish the anastomosis between the ileum and the remaining ascending colon by stapling with a gastrointestinal anastomosis stapler to join the two limbs of bowel. Use another thoracoabdominal stapler to close the remaining enterotomy and colotomy. Close the defect in the mesentery using an absorbable running stitch, and then place the bowel back within the abdominal cavity. Then close the fascial defect in two layers and insufflate the abdomen again to irrigate and inspect. Remove all remaining trocars under direct vision. Close the skin using a running subcuticular absorbable stitch.
Coding confusion identified and debunked
Following trends in national coding blogs and websites, institutional coders have concluded that extracorporeal extraction and creation of an anastomosis is an open procedure, making the operation an open colectomy. This deduction incorrectly focuses on the limited portion of the procedure performed extracorporeally (specimen extraction and/or creation of anastomosis) and fails to recognize that the beginning, end, and overwhelming majority of the procedure is performed intracorporeally with laparoscopic camera guidance under pneumoperitoneum.
This confusion likely involves use of International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10-PCS) codes, which classify procedures performed in the inpatient setting. Facilities, not physicians, report ICD-10-PCS codes, and these codes define various approaches that do not correspond to CPT coding (open, closed, percutaneous, laparoscopic). For example, the ICD-10-PCS “open endoscopic” approach is defined as “cutting through the skin or mucous membrane and any other body layers necessary to expose a body part, and introduction of instrumentation to reach and visualize the site of the procedure.” A second example is the “open with percutaneous endoscopic assistance” approach defined as “cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure, and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure.”†
Coders have referenced each of these ICD-10-PCS approaches to claim that laparoscopic abdominal procedures that include a minor incision for hand-assistance laparoscopy (HAL) or for extraction or exteriorization of the bowel should be coded as an open procedure. This coding approach is incorrect even in comparison with ICD-10-PCS, which defines an “open” procedure as “cutting through the skin and mucous membrane and any other body layers necessary to expose the site of the procedure.” The extension of the trocar incision or a separate small incision to exteriorize the bowel is not an open dissection that exposes the site of the procedure—the abdominal cavity. The minor incision does not allow exposure of the abdominal cavity for the laparoscopic diagnostic examination, mobilization of the intestine, vascular ligation, and final irrigation and inspection.
Colectomy codes are identified as either open or laparoscopic. The ACS, ASCRS, and SAGES agree that the procedures described as open in the CPT code set have always clearly meant that a laparotomy was performed and that the procedures described as laparoscopic have always clearly meant that the beginning, end, and most or all of the work in between was performed using trocars and laparoscopic instruments. Robotic-assistance, hand-assistance, or minor incision for specimen extraction with or without extracorporeal work is still considered a laparoscopic procedure.
To be clear, the trends in national coder discussions contradict the original descriptions and intent of “laparoscopic colectomy” procedures. Two key points have been established. First, an incision made either by extending a trocar site, at an alternative location (for example, midline), or for HAL does not constitute an open procedure. Second, the method used to perform most of the procedure—via laparoscopy or via a laparotomy—establishes the appropriate code to report. Extraction of a specimen and/or creation of anastomosis does not constitute the majority of the procedure. These conclusions are supported by the description of work inherent to the colectomy CPT codes during their development and valuation.
Learn more about correct coding at an ACS General Surgery Coding Workshop. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. For more information about the workshops, including details for registering for a 2019 class, visit the ACS website.
*All specific references to CPT codes and descriptions are ©2018 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.
†Centers for Medicare & Medicaid Services. ICD-10-PCS guidelines. Available at: www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html. Accessed April 17, 2019.