How To Use The CPT Codes For Small Bowel Resection

Small bowel resection is a surgical procedure performed to remove a portion of the small intestine. It is commonly indicated for conditions such as cancer, Crohn’s disease, obstruction, or trauma. This guide provides an exhaustive exploration of CPT codes for small bowel resections, their documentation requirements, and billing tips.

1. Overview of Small Bowel Resection CPT Codes

CPT codes for small bowel resection are assigned based on the specific surgical techniques, the presence of anastomosis, and any associated procedures. The primary factors influencing code selection include:

• The portion of the bowel resected.
• The surgical approach (e.g., open or laparoscopic).
• Whether the procedure included an anastomosis or stoma creation.
• Additional complexities such as adhesion lysis.

Accurate coding depends on thorough documentation of these aspects.

2. Specific CPT Codes for Small Bowel Resection

The following are the key CPT codes used for small bowel resections:

A. Open Small Bowel Resection

Open resections involve making an incision in the abdomen to access and remove the affected bowel segment.

• CPT 44120: Enterectomy, resection of small intestine, single resection and anastomosis.
  • Lay Term: This procedure involves removing a segment of the small intestine and reconnecting the remaining sections.
  • Indications: Crohn’s disease, tumors, or ischemia affecting a single segment.
  • Documentation: Include details about the segment removed, the technique used for anastomosis, and the reason for resection.
• CPT 44121: Each additional resection with anastomosis (list separately in addition to primary procedure).
  • Lay Term: Used when multiple bowel segments are resected and reconnected during the same procedure.
  • Billing Tip: Always pair with CPT 44120 and document the need for multiple resections.

B. Laparoscopic Small Bowel Resection

Laparoscopic procedures use minimally invasive techniques to perform bowel resections.

• CPT 44202: Laparoscopy, surgical; enterectomy, resection of small intestine, with anastomosis.
  • Lay Term: A segment of the small bowel is resected laparoscopically and the ends are reconnected.
  • Indications: Patients requiring a less invasive approach due to comorbidities or preference.
  • Documentation: Specify the laparoscopic approach and describe the portion of the bowel removed.

3. Additional Procedures and Associated Codes

A. Procedures with Stoma Creation

• CPT 44143: Colectomy, partial; with end ileostomy.
  • Lay Term: Removal of a portion of the colon with the creation of an ileostomy.
  • Documentation: Note the portion of the colon removed and the details of stoma creation.
• CPT 44310: Ileostomy or jejunostomy, non-tube.
  • Lay Term: Creation of a stoma in the ileum or jejunum.
  • Indications: Conditions requiring diversion of bowel contents, such as severe Crohn’s disease.

B. Adhesion Lysis

• CPT 44005: Enterolysis (freeing of intestinal adhesion) separate procedure.
  • Lay Term: Removal of adhesions in the small intestine.
  • Documentation: Clearly describe the extent and complexity of adhesions removed.

4. Administration and Billing Tips

A. Documentation Requirements

1. Surgical Details: Describe the portion of the bowel resected, the technique used, and any complications.
2. Anastomosis Type: Specify whether the connection was end-to-end, side-to-side, or another method.
3. Stoma Creation: If performed, include detailed descriptions of stoma placement and type.

B. Modifiers

• Modifier 51: Use for multiple procedures.
• Modifier 22: Report increased procedural complexity.
• Modifier 59: Indicate a distinct procedural service when additional procedures (e.g., lysis of adhesions) are performed.

C. Avoiding Common Errors

• Inaccurate Documentation: Ensure the operative note clearly states the extent of the procedure.
• Bundling Issues: Be cautious of bundled services, such as adhesion lysis, which may not be separately billable unless significant.
• Incorrect Approach Coding: Confirm whether the procedure was open or laparoscopic to select the correct code.

5. Practical Scenarios and Coding Examples

Scenario 1: Single Segment Resection with Anastomosis

• Patient: A 55-year-old with small bowel obstruction.
• Procedure: Open enterectomy with end-to-end anastomosis.
• Codes:
  • CPT 44120 (single resection with anastomosis).

Scenario 2: Multiple Resections

• Patient: A 63-year-old with Crohn’s disease affecting two separate small bowel segments.
• Procedure: Open enterectomy with anastomosis for both segments.
• Codes:
  • CPT 44120 (primary resection).
  • CPT 44121 (each additional resection).

Scenario 3: Laparoscopic Resection

• Patient: A 47-year-old with a benign tumor in the small intestine.
• Procedure: Laparoscopic small bowel resection with anastomosis.
• Codes:
  • CPT 44202 (laparoscopic resection with anastomosis).