How To Use CPT Code 44157

CPT 44157 describes the surgical procedure known as colectomy with ileoanal anastomosis, including loop ileostomy and rectal mucosectomy, when performed. 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 44157?

CPT 44157 is a code used to describe a surgical procedure called colectomy with ileoanal anastomosis, which involves the removal of the total colon and rectum. During this procedure, the provider connects the ileum (the last part of the small intestine) to the anus. Additionally, the provider may perform a rectal mucosectomy, which involves the removal of the mucosa from the rectum. This code also includes the creation of a loop ileostomy, which is an external opening connected to a loop of ileum to allow for the emptying of the intestines.

2. Official Description

The official description of CPT code 44157 is: ‘Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed.’

3. Procedure

1. The surgical procedure begins with the provider making an incision in the abdomen, extending from the xiphoid to the pubis.
2. Any adhesions present at the site are dissected by the provider.
3. The structures surrounding the colon and rectum are carefully dissected by the provider.
4. The provider transects the intestines at the ileocecal valve, which is the junction between the large and small intestines, as well as the distal part of the rectum.
5. If necessary, the provider may remove the mucosa of the rectum up to the level of the pelvic floor, taking care not to affect the surrounding nerves.
6. The colon and rectum are sent to pathology for further analysis.
7. The provider then connects the distal end of the ileum to the anus using sutures.
8. In some cases, the provider may create a loop ileostomy by bringing a loop of the ileum up to the skin and connecting it to an opening in the skin. This allows for the emptying of the intestines and may be temporary to allow for healing.
9. Drains are placed at the site of the incision in the abdomen, and the area is flushed with sterile solution.
10. The provider checks for any bleeding and staples the incision used for colectomy in the abdomen.

4. Qualifying circumstances

CPT 44157 is typically performed on patients who have colorectal cancer or Crohn’s disease, an inflammatory disease that affects the gastrointestinal tract. These patients may experience symptoms such as abdominal pain, fever, and weight loss. The procedure is performed by a qualified healthcare provider and may require the use of a standardized surgical approach. It is important to note that not all patients with colorectal cancer or Crohn’s disease will require a colectomy with ileoanal anastomosis, and the decision to perform this procedure is based on individual patient factors and the provider’s clinical judgment.

5. When to use CPT code 44157

CPT code 44157 should be used when a provider performs a colectomy with ileoanal anastomosis, including loop ileostomy and rectal mucosectomy, as described in the official description. It is important to accurately document the specific details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 44157, the provider must document the following information:

• Patient’s diagnosis necessitating the colectomy with ileoanal anastomosis
• Details of the procedure, including the use of loop ileostomy and rectal mucosectomy
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed during the same surgical session
• Any complications or unexpected findings during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 44157, it is important to ensure that the documentation supports the use of this code. The procedure should be performed by a qualified healthcare provider and meet the criteria outlined in the official description. It is also important to follow any specific billing guidelines provided by the payer. Additionally, it is important to review the medical record to ensure accurate coding and billing for any additional procedures performed during the same surgical session.

8. Historical information

CPT code 44157 was added to the Current Procedural Terminology system on January 1, 2007. There have been no updates or changes to the code since its addition. However, it is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient with colorectal cancer undergoes a colectomy with ileoanal anastomosis, including loop ileostomy and rectal mucosectomy, performed by a qualified surgeon.
2. A patient with Crohn’s disease requires a colectomy with ileoanal anastomosis, including loop ileostomy and rectal mucosectomy, to manage their symptoms and improve their quality of life.
3. A provider performs a colectomy with ileoanal anastomosis, including loop ileostomy and rectal mucosectomy, on a patient with a history of inflammatory bowel disease.