How To Use CPT Code 45136

CPT 45136 describes the excision of an ileoanal reservoir with ileostomy. 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 45136?

CPT 45136 is used to describe the surgical procedure in which the provider removes an ileoanal reservoir and creates an ileostomy. This involves diverting the ileum, the terminal portion of the small intestine, out through an opening in the abdomen. The ileoanal reservoir is an internal pouch made up of the small intestine that acts as a storage place for stool in patients who have had their colon removed. The stored stool is then expelled out of the anus several times during the day.

2. Official Description

The official description of CPT code 45136 is the excision of an ileoanal reservoir with ileostomy. It is important to note that CPT code 45136 should not be reported in conjunction with codes 44005 and 44310.

3. Procedure

1. When performing CPT 45136, the provider begins by making an incision in the abdomen and dissecting down to locate the ileoanal reservoir.
2. The provider then excises the ileoanal reservoir, which is where the ileum was previously joined to the anus.
3. The anus is closed, and the provider creates a small opening in the abdomen known as a stoma.
4. The terminal end of the ileum is brought out through the stoma, and a special bag is attached to collect waste products.
5. The provider ensures that there is no bleeding and closes the abdominal incision by suturing the layers of tissue together.

4. Qualifying circumstances

CPT 45136 is performed on patients who have an ileoanal reservoir and require its removal. This procedure is typically done in patients who have had their colon removed and have been using an ileoanal reservoir as a storage place for stool. It is important to note that CPT 45136 should not be reported in conjunction with codes 44005 and 44310.

5. When to use CPT code 45136

CPT code 45136 should be used when the provider performs the excision of an ileoanal reservoir with ileostomy. It is important to note that CPT 45136 should not be reported in conjunction with codes 44005 and 44310.

6. Documentation requirements

To support a claim for CPT 45136, the provider must document the following information:

• Patient’s diagnosis and the need for the excision of the ileoanal reservoir
• Details of the procedure, including the incision, excision of the reservoir, creation of the stoma, and closure of the incision
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 45136, ensure that the procedure meets the criteria for this code. It is important to note that CPT 45136 should not be reported in conjunction with codes 44005 and 44310. Review the documentation requirements and ensure that all necessary information is included in the claim. Follow the appropriate coding guidelines and modifiers, if applicable, to accurately report CPT 45136.

8. Historical information

CPT 45136 was added to the Current Procedural Terminology system on January 1, 2002. It was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient with an ileoanal reservoir undergoes CPT 45136 to have the reservoir removed and an ileostomy created.
2. A provider performs CPT 45136 on a patient who no longer requires the ileoanal reservoir and needs an ileostomy.
3. CPT 45136 is performed on a patient with complications related to the ileoanal reservoir, necessitating its removal and the creation of an ileostomy.
4. A patient with a history of colon removal undergoes CPT 45136 to remove the ileoanal reservoir and create an ileostomy for better stool management.
5. A provider performs CPT 45136 on a patient who has developed an infection in the ileoanal reservoir, requiring its removal and the creation of an ileostomy.
6. CPT 45136 is performed on a patient with a malfunctioning ileoanal reservoir, necessitating its removal and the creation of an ileostomy for improved stool elimination.
7. A patient with a recurrent condition undergoes CPT 45136 to remove the ileoanal reservoir and create an ileostomy as a long-term solution.
8. A provider performs CPT 45136 on a patient who experiences chronic pain and discomfort due to the ileoanal reservoir, requiring its removal and the creation of an ileostomy.
9. CPT 45136 is performed on a patient with a history of complications related to the ileoanal reservoir, necessitating its removal and the creation of an ileostomy for improved quality of life.
10. A patient with a non-functioning ileoanal reservoir undergoes CPT 45136 to remove the reservoir and create an ileostomy for better stool management.