How To Use CPT Code 44155

CPT 44155 describes the surgical procedure known as colectomy with proctectomy and ileostomy. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44155?

CPT 44155 is a code used to describe a surgical procedure called colectomy with proctectomy and ileostomy. This procedure involves the removal of the entire colon and rectum, and the creation of an ileostomy, which is an artificial opening in the abdominal wall that allows waste to be eliminated from the body.

2. Official Description

The official description of CPT code 44155 is: ‘Colectomy, total, abdominal, with proctectomy; with ileostomy.’ This code is used when a provider performs a complete removal of the colon and rectum, and creates an ileostomy to divert waste from the body.

3. Procedure

1. In this procedure, the provider makes a midline abdominal incision from the xiphoid to the pubis.
2. The surrounding structures are dissected to reach the affected area of the colon and rectum.
3. The provider frees the colon and rectum from their attachments and ligates the blood vessels.
4. The upper rectum and terminal ileum, which is the end of the small intestine, are divided.
5. The total colon and part of the rectum are removed.
6. The remaining rectum is also removed.
7. The terminal ileum is brought out to the skin of the abdomen through a separate incision as an ileostomy.
8. The provider checks for bleeding, removes any instruments, and closes the incision in the abdomen.

4. Qualifying circumstances

CPT 44155 is performed on patients who require the complete removal of the colon and rectum, such as those with colorectal cancer or Crohn’s disease. The procedure is typically performed by a qualified surgeon in an abdominal setting. It is important to note that this code is specific to cases involving a proctectomy and ileostomy.

5. When to use CPT code 44155

CPT code 44155 should be used when a provider performs a total colectomy with proctectomy and creates an ileostomy. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve a proctectomy or ileostomy, a different code should be used to accurately represent the performed procedure.

6. Documentation requirements

To support a claim for CPT 44155, the provider must document the following information:

• Patient’s diagnosis necessitating the colectomy with proctectomy and ileostomy
• Details of the procedure, including the specific steps performed
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 44155, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed by a qualified surgeon in an abdominal setting. It is also important to follow any additional guidelines or requirements set forth by the payer or insurance company. It is recommended to review the complete set of billing guidelines and consult with a coding specialist to ensure accurate and appropriate billing.

8. Historical information

CPT 44155 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A surgeon performs a colectomy with proctectomy and ileostomy on a patient with colorectal cancer.
2. A patient with Crohn’s disease undergoes a colectomy with proctectomy and ileostomy to manage their condition.
3. A qualified surgeon performs a colectomy with proctectomy and ileostomy on a patient with a severe gastrointestinal infection.
4. A patient with a history of chronic ulcerative colitis undergoes a colectomy with proctectomy and ileostomy to alleviate symptoms.
5. A provider performs a colectomy with proctectomy and ileostomy on a patient with a large colon polyp that cannot be removed through other means.