How To Use CPT Code 44025

CPT 44025 describes a specific procedure performed on the colon that involves making an incision, exploring the affected area, and performing biopsy or removal of a foreign body. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44025?

CPT 44025 is a code used to describe a surgical procedure performed on the colon. It involves making an incision in the abdomen, exploring the colon, and obtaining biopsy samples or removing foreign bodies. This procedure is typically performed when there is a need to examine the colon or address specific issues such as biopsies or foreign body removal.

2. Official Description

The official description of CPT code 44025 is: ‘Colotomy, for exploration, biopsy(s), or foreign body removal.’ It is important to note that this code specifically refers to the exploration, biopsy, or removal of foreign bodies in the colon. For exteriorization of the intestine, a different set of codes should be used.

3. Procedure

1. During the procedure, the healthcare provider prepares the patient appropriately and ensures they are anesthetized.
2. An incision is made in the abdomen to access the colon.
3. The provider then explores the colon, examining the affected area and identifying any abnormalities or foreign bodies.
4. If necessary, the provider obtains one or more biopsy samples for further analysis.
5. In cases where there are foreign bodies present, the provider removes them from the colon.
6. After completing the necessary procedures, the provider ensures control of bleeding and closes the incision in the abdomen.

4. Qualifying circumstances

CPT 44025 is typically performed when there is a need to explore the colon, obtain biopsy samples, or remove foreign bodies. The procedure is indicated for patients who have specific conditions or symptoms that require further examination or intervention in the colon. It is important to note that this code specifically refers to procedures performed on the colon and not other parts of the intestines.

5. When to use CPT code 44025

CPT code 44025 should be used when a healthcare provider performs a colotomy procedure for exploration, biopsy, or foreign body removal in the colon. It is important to accurately document the specific reason for the procedure and ensure that it aligns with the official description of the code. This code should not be used for procedures performed on other parts of the intestines.

6. Documentation requirements

To support a claim for CPT 44025, the healthcare provider must document the following information:

• Reason for the procedure, including any specific symptoms or conditions that necessitated exploration, biopsy, or foreign body removal in the colon
• Details of the procedure, including the specific steps taken and any complications encountered
• Documentation of any biopsy samples obtained, including the number and location
• Documentation of any foreign bodies removed from the colon
• Details of the closure of the incision and any measures taken to control bleeding
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 44025, it is important to ensure that the procedure performed aligns with the official description of the code. The healthcare provider should accurately document the details of the procedure and any additional services provided. It is also important to follow any specific billing guidelines provided by insurance companies or payers. Additionally, it is important to note that CPT code 44025 should not be reported with other codes that are already performed in the previous seven days.

8. Historical information

CPT code 44025 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A surgeon performing a colotomy procedure to explore the colon and obtain biopsy samples for a patient with suspected colon cancer.
2. A gastroenterologist removing a foreign body from the colon of a patient who accidentally ingested a small object.
3. A general surgeon performing a colotomy procedure to explore the colon and address symptoms of unexplained abdominal pain.
4. A pediatric surgeon performing a colotomy procedure to explore the colon and obtain biopsy samples for a child with suspected inflammatory bowel disease.
5. An emergency medicine physician performing a colotomy procedure to remove a foreign body from the colon of a patient who presented with acute abdominal pain.
6. A colorectal surgeon performing a colotomy procedure to explore the colon and obtain biopsy samples for a patient with chronic diarrhea and weight loss.
7. A surgical oncologist performing a colotomy procedure to explore the colon and remove a foreign body in a patient with a history of diverticulitis.
8. A gastroenterologist performing a colotomy procedure to explore the colon and obtain biopsy samples for a patient with suspected Crohn’s disease.
9. A general surgeon performing a colotomy procedure to remove a foreign body from the colon of a patient who accidentally swallowed a sharp object.
10. A colorectal surgeon performing a colotomy procedure to explore the colon and obtain biopsy samples for a patient with a family history of colon cancer.