How To Use CPT Code 44158

CPT 44158 describes a specific surgical procedure involving colectomy, total abdominal, with proctectomy. 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 44158?

CPT 44158 is a code used to describe a surgical procedure known as colectomy, total abdominal, with proctectomy. This procedure involves the removal of the entire colon and rectum, and may also include the removal of the rectal mucosa. The end of the small bowel is then connected to the anus, creating a reservoir using the ileum folded in an “S” or “J” shape.

2. Official Description

The official description of CPT code 44158 is: ‘Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed.’

3. Procedure

1. The patient is positioned supine on the operating table and prepared for surgery.
2. The surgeon makes a long abdominal incision, typically from the xiphoid to the pubis.
3. The colon and rectum are freed from their attachments, and the blood vessels supplying them are ligated.
4. A stapler is used to transect the colon at the ileocecal valve and at the distal rectum.
5. The mucosa of the rectum may be stripped away, and the surgeon connects the ileum to the anus.
6. The distal ileum is folded into an “S” or “J” shape to create a reservoir.
7. A loop of the ileum is brought up to the skin level and attached to create a temporary fistula for healing.
8. The surgeon ensures hemostasis and closes the abdominal incision in layers.

4. Qualifying circumstances

CPT 44158 is performed on patients who require a total colectomy with removal of the rectum, along with the creation of an ileoanal anastomosis and the formation of an ileal reservoir. This procedure is typically indicated for conditions such as colon cancer, other diseases of the colon, necrosis from entrapped bowel, or trauma. It is important to note that this code is specifically for open approaches, and a different code should be used for laparoscopic procedures.

5. When to use CPT code 44158

CPT code 44158 should be used when performing a total colectomy with proctectomy, along with the creation of an ileoanal anastomosis and an ileal reservoir. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure is performed laparoscopically, a different code (44211) should be used.

6. Documentation requirements

Documentation for CPT code 44158 should include the following information:

• Patient’s diagnosis necessitating the colectomy and proctectomy
• Details of the procedure performed, including the creation of an ileoanal anastomosis and an ileal reservoir
• Date of the surgery
• Start and end times of the procedure
• Any additional procedures performed, such as rectal mucosectomy
• Any complications or unexpected findings during the surgery
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT code 44158, it is important to ensure that the documentation supports the specific criteria outlined in the code description. This includes the total colectomy with proctectomy, creation of an ileoanal anastomosis, and formation of an ileal reservoir. It is also important to use the appropriate code for the approach used (44211 for laparoscopic procedures). Additionally, be aware of any specific billing guidelines or requirements from insurance providers or payers.

8. Historical information

CPT code 44158 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. It is important to stay updated with any changes or revisions to ensure accurate coding and billing.

9. Examples

1. A patient with colon cancer undergoes a total colectomy with proctectomy, along with the creation of an ileoanal anastomosis and an ileal reservoir.
2. An individual with ulcerative colitis requires a total colectomy with proctectomy, and an ileoanal anastomosis is performed to create an ileal reservoir.
3. A patient with familial adenomatous polyposis undergoes a total colectomy with proctectomy, and an ileoanal anastomosis is created to form an ileal reservoir.
4. An individual with ischemic colitis requires a total colectomy with proctectomy, and an ileoanal anastomosis is performed to create an ileal reservoir.
5. A patient with trauma to the colon and rectum undergoes a total colectomy with proctectomy, and an ileoanal anastomosis is created to form an ileal reservoir.