How To Use CPT Code 44111

CPT 44111 describes the excision of one or more lesions from the small or large intestine without the need for anastomosis, exteriorization, or fistulization. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44111?

CPT 44111 is used to describe the surgical procedure of removing one or more lesions from the small or large intestine. This procedure does not require the creation of an anastomosis, exteriorization, or fistula. Instead, the provider makes multiple incisions to access and excise the targeted areas of the intestine.

2. Official Description

The official description of CPT code 44111 is the excision of one or more lesions from the small or large intestine without the need for anastomosis, exteriorization, or fistulization. It is important to note that anastomosis refers to the connection between two structures, while exteriorization involves exposing an attached organ or part outside of a body cavity. Fistulization, on the other hand, is the formation of an abnormal passageway between structures.

3. Procedure

1. When performing CPT 44111, the provider begins by making an incision in the abdomen and identifying the specific area of the intestine that contains the lesion(s).
2. Multiple incisions are then made to access all the targeted areas of the intestine.
3. The provider proceeds to excise all the lesions, ensuring that the enterotomy (colotomy if in the colon) is closed using techniques such as stapling or suturing.
4. After completing the excision and closure, the provider ensures control of bleeding and appropriately closes the abdominal incision.

4. Qualifying circumstances

CPT 44111 is performed on patients who require the removal of one or more lesions from the small or large intestine. The procedure does not involve the creation of an anastomosis, exteriorization, or fistula. It is important to note that anastomosis refers to the connection between two structures, while exteriorization involves exposing an attached organ or part outside of a body cavity. Fistulization, on the other hand, is the formation of an abnormal passageway between structures.

5. When to use CPT code 44111

CPT code 44111 should be used when a provider performs the excision of one or more lesions from the small or large intestine without the need for anastomosis, exteriorization, or fistulization. It is important to accurately document the procedure and ensure that it meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 44111, the provider must document the following information:

• The specific diagnosis or indication for the excision procedure
• The location and number of lesions being excised
• The method used to close the enterotomy or colotomy
• Any additional procedures performed during the same operative session
• Any complications or unexpected findings encountered during the procedure
• The provider’s signature and credentials

7. Billing guidelines

When billing for CPT 44111, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The excision should not involve the creation of an anastomosis, exteriorization, or fistula. It is also important to accurately document the procedure and any additional services provided during the same operative session. It is recommended to review the specific billing guidelines provided by the payer to ensure proper reimbursement.

8. Historical information

CPT 44111 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been changes to the code description, including updates in 2002 and 2010. It is important to stay updated with any changes or revisions to ensure accurate coding and billing.

9. Examples

1. A surgeon performs the excision of multiple lesions from the small intestine without the need for anastomosis, exteriorization, or fistulization.
2. A gastroenterologist removes a single lesion from the large intestine using multiple enterotomies.
3. A colorectal surgeon excises multiple lesions from the small and large intestine without the need for anastomosis, exteriorization, or fistulization.
4. A general surgeon performs the excision of a single lesion from the small intestine using multiple incisions.
5. A surgical team removes multiple lesions from the large intestine without the need for anastomosis, exteriorization, or fistulization.
6. An oncologist performs the excision of multiple lesions from the small and large intestine using multiple enterotomies.
7. A pediatric surgeon removes a single lesion from the small intestine without the need for anastomosis, exteriorization, or fistulization.
8. A gastrointestinal surgeon excises multiple lesions from the large intestine using multiple incisions.
9. A surgical team removes multiple lesions from the small and large intestine without the need for anastomosis, exteriorization, or fistulization.
10. An oncologist performs the excision of a single lesion from the small and large intestine using multiple enterotomies.