How To Use CPT Code 44210

CPT 44210 describes the laparoscopic surgical procedure for total colectomy, without proctectomy, with either ileostomy or ileoproctostomy. 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 44210?

CPT 44210 is used to describe a laparoscopic surgical procedure for total colectomy, without proctectomy, with either ileostomy or ileoproctostomy. This code is specifically used when the provider removes the entire colon through the abdomen and connects the ileum to either the rectum or an external stoma. It is important to note that this code is only applicable for laparoscopic procedures, and if an open approach is used, a different code should be used.

2. Official Description

The official description of CPT code 44210 is: ‘Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy.’ This code was added to the Current Procedural Terminology system on January 1, 2003. It is important to note that Medicare has classified this procedure as an Inpatient Only (IPO) service since 2017.

3. Procedure

1. The laparoscopic total colectomy procedure begins with the patient being appropriately prepped and anesthetized.
2. The provider makes an incision at the umbilicus to insert a camera and instruments into the abdomen.
3. Additional small incisions are made to allow for better visualization and access to the colon.
4. The provider uses various instruments to cut apart any adhesions, free the colon from its attachments, and ligate the blood vessels.
5. The colon is transected at the ileocecal valve and the colorectal junction.
6. Depending on the patient’s condition, the provider either creates an ileostomy by connecting the terminal ileum to an incision in the skin or connects the terminal ileum directly to the rectum.
7. Hemostasis is ensured, and the abdominal incisions, excluding the ileostomy, are closed in layers.
8. This procedure is typically performed in patients with colorectal cancer, Crohn’s disease, or ulcerative colitis.

4. Qualifying circumstances

CPT 44210 is applicable to patients who require a total colectomy without proctectomy and either an ileostomy or ileoproctostomy. This procedure is commonly performed in patients with colorectal cancer, Crohn’s disease, or ulcerative colitis. It is important to note that this code is specific to laparoscopic procedures and should not be used for open approaches.

5. When to use CPT code 44210

CPT code 44210 should be used when a laparoscopic total colectomy is performed without proctectomy, and either an ileostomy or ileoproctostomy is created. It is important to ensure that the procedure is performed using a laparoscopic approach and not an open approach. If an open approach is used, a different code should be selected.

6. Documentation requirements

To support a claim for CPT code 44210, the following documentation is required:

• Patient’s diagnosis necessitating the total colectomy
• Details of the laparoscopic approach used
• Description of the specific procedure performed, including the creation of an ileostomy or ileoproctostomy
• Any additional procedures or interventions performed during the same operative session
• Documentation of hemostasis and closure of abdominal incisions
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 44210, it is important to ensure that the procedure was performed laparoscopically and without proctectomy. This code should not be reported if an open approach was used. Additionally, it is important to follow any specific billing guidelines provided by payers or Medicare regarding the use of this code. It is also important to note that CPT code 44210 is classified as an Inpatient Only (IPO) service by Medicare.

8. Historical information

CPT code 44210 was added to the Current Procedural Terminology system on January 1, 2003. Since its addition, there have been no updates or changes to the code. However, it is important to stay updated with any changes or revisions to coding guidelines and payer requirements.

9. Examples

1. A patient with ulcerative colitis undergoes a laparoscopic total colectomy without proctectomy, with the creation of an ileostomy.
2. A laparoscopic total colectomy without proctectomy is performed on a patient with colorectal cancer, and an ileoproctostomy is created.
3. A patient with Crohn’s disease undergoes a laparoscopic total colectomy without proctectomy, with the creation of an ileostomy.
4. A laparoscopic total colectomy without proctectomy is performed on a patient with familial adenomatous polyposis, and an ileoproctostomy is created.
5. A patient with diverticulitis undergoes a laparoscopic total colectomy without proctectomy, with the creation of an ileostomy.