Code Ostomy Takedowns with Ease

If you work for a surgeon specializing in colorectal procedures, chances are you have seen your fair share of ostomy takedown procedures. When you first start checking CPT for a code for a “takedown,” though, you may find yourself coming up empty. The reason for this is that surgeons use the term takedown in their operative reports while CPT uses the word “closure” in the codes that cover this procedure. Both terms really have the same meaning, but until you know about the difference in language you may see in reports verses what you will see in the CPT manual, the whole thing can be pretty confusing. So let’s breakdown the terminology and codes for an “ostomy takedown” and see how that looks in CPT so you can quickly choose the correct code.

CPT describes an “ostomy takedown procedure” as “closure of an enterostomy.” An enterostomy is a surgically-created connection between part of the intestine and another structure. We can confirm the definition of enterostomy by breaking the word down into its parts: entero- means “of or pertaining to the intestine” (this could refer to either the small or the large intestine) while -ostomy means “an artificial opening between two structures.” So when we put these word parts together we have “an artificial opening between a part of the intestine and another structure.” In the context of these codes, the artificial connection was made between one end of the intestine and the abdominal wall. Some common enterostomies you may see include an ileostomy (connection between part of the last segment of the small intestine and the abdominal wall) and a colostomy (connection between any part of the large intestine, aka as the colon, and the abdominal wall). The CPT codes for the takedown procedure start with the word “closure.” The reason we see the word “closure” is because the surgeon will ultimately close up that artificial opening (or ostomy site) on the abdominal wall in a takedown procedure. So surgeons refer to these procedures as a “takedown” clinically because they are taking the end of the colon or small intestine that was connected to the abdominal wall back down into the abdomen while CPT calls these “closure of an enterostomy” because the surgeon is ultimately closing up that artificial opening on the abdominal wall. Both terms again really refer to the same procedure, but hopefully this explanation will help you line up the language you see in operative reports and what you see in your CPT manual.

With those definitions in mind, here are the three code choices for closure of an enterostomy:

• CPT 44620: Closure of enterostomy, large or small intestine

• CPT 44625: Closure of enterostomy, large or small intestine; with resection and anastomosis (other than colorectal)

• CPT 44626: Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (e.g., closure of Hartmann type procedure)

Let’s start breaking down the difference in these codes. Starting with CPT 44620, this is your code for your “basic” takedown procedure. In this procedure, the surgeon disconnects the end of the small or large intestine from the abdominal wall and reconnects that end to the remaining intestine back inside the body. He then closes the former ostomy opening on the abdominal wall. No part of the intestine is removed in this procedure. Instead, the end that was attached to the abdominal wall is simply reconnected (aka anastomosed) to the remaining intestine without resecting part of the intestine.

For CPT 44625, the physician is still disconnecting the end of the small or large intestine from the abdominal wall, but before reconnecting the end of the intestine to the remaining intestine in the body, part of the intestine that was connected to the abdominal wall and/or part of the remaining intestine “stump” (the end of the intestine that was inside the body) will be resected and removed. After removing the appropriate amount of intestine, the two ends of the intestine will be anastomosed back together. For CPT 44625, the anastomosis performed is any anastomosis other than colorectal. So in this procedure, you may see various parts of the intestine reconnected such as ileum to ileum, ileum to remaining colon, colon to colon, etc. If two structures other than the colon and the rectum are reconnected after removing part of the intestine and closing the ostomy site on the abdominal wall, it’s a 44625.

Finally, for CPT 44626, this procedure includes very similar work to what is described by CPT 44625, but in this procedure, the two structures anastomosed are the colon and the rectum (aka a colorectal anastomosis). This procedure may also involve resection of part of the remaining colon and part of the remaining rectum before creating that colorectal anastomosis. You will notice in the parentheses in the code description that CPT states this procedure may be coded for closure of a “Hartmann’s type procedure.” In a typical Hartmann’s procedure, one end of the colon is brought out to the abdominal wall as a colostomy while the remaining rectal “stump” is stapled closed. So in reversing a Hartmann’s, the surgeon would typically resect part of the colon that was attached to the abdominal wall and maybe “clean up” the end of the rectal stump and then perform a colorectal anastomosis. That’s why closing the ostomy created during a Hartmann’s procedure would typically fall under CPT 44626. It is important to note, though, that most but not all Hartmann procedure takedowns would be coded as 44626. In a modified Hartmann’s procedure, the surgeon will connect one end of the colon to the abdominal wall as a colostomy and then staple closed a “long Hartmann’s stump” that includes part of the sigmoid colon plus the rectum. If the surgeon closes the ostomy at a later date and the anastomosis created is between part of the colon that was connected to the abdominal wall as an ostomy and the sigmoid colon (rather than the rectum), you would code CPT 44625 (since the anastomosis would be colon to colon instead of colorectal). Small details here would make a difference in the coding.

Now that we have reviewed the codes, let’s look at a couple of examples to illustrate appropriate coding of these procedures.

Example #1: After sterile prep and drape, we made an incision through our previous midline laparotomy. Dense adhesions were encountered, but we were eventually able to gain access to the transverse colonic stump. We removed roughly 5 cm of colon to ensure no ischemic bowel remained. We then turned our attention to the abdominal wall where we circumferentially dissected around the ileostomy site. The end of the ileum appeared dusky so we removed 10 cm of ileum and then brought the remaining intestine down into the abdomen. The remaining ileum and transverse colon were aligned and using an EEA stapler, the anastomosis was complete. The ends of the bowel came together nicely in a tension-free anastomosis. We checked to ensure we had an airtight anastomosis and applied some Arista powder to ensure hemostasis. We then closed our opening on the abdominal wall and closed our midline incision. The patient tolerated the procedure well.

Answer Example #1: The bolded portions of the note above are keys to selecting the correct CPT code. We first see the physician enter the abdomen (a laparotomy is an incision into the abdomen), and he finds the “transverse colonic stump” (or the part of the intestine that was stapled off in the body during the prior surgery where the ostomy was created). He “removes” 5 cm of transverse colon (which is our first intestinal resection). He then comes up to the abdominal wall and circumferentially dissects (or separates all the way around) the connect between the ileostomy (the end of the ileum) and the abdominal wall. He then performs a second intestine resection, removing 10 cm of the ileum. Then he brings the ileum back into the abdomen, lines up the ileum and the transverse colon, and using a stapler creates an anastomosis (a connection between the remaining ileum and the colon). After making sure his anastomosis is intact by testing for leaks and controlling any bleeding (which is all part of the main procedure), he closes the opening from the ostomy on the abdominal wall. So we have closure of an enterostomy (in this case an ileostomy), with resection of intestine, and an anastomosis other than colorectal (since the anastomosis is between the ileum and the transverse colon). Those details support CPT 44625.

Example #2: After sterile prep and drape, we made an incision through our previous midline laparotomy. Dense adhesions were encountered, and we spent 90 minutes lysing adhesions to gain access to the abdomen. Access was very difficult due to multiple prior abdominal surgeries. Eventually we located our rectal stump. We opened up the prior sutures at the rectal stump and then turned our attention to the abdominal wall. We then circumferentially freed the colostomy from the abdominal wall. We resected 15 cm of colon then brought the remaining intestine down into the abdomen, ensuring we had adequate length to reach the rectum. The remaining colon and rectum were aligned. We passed the anvil of our EEA stapler into the remaining colonic end and passed the stapler via the anus. With a single fire, the anastomosis was complete. We introduced water into the pelvis and air into the colon via a rigid proctoscope to ensure there were no bubbles and verify that our anastomosis was intact. With this complete, we then closed the prior colostomy site on the abdominal wall and closed our midline incision. The patient tolerated the procedure well.

Answer Example #2: The bolded portions of the note above are keys to our code selection. We first see the surgeon entering the abdomen. In this case, the entry into the abdomen is significantly more complex than normal (he tells us he spent 90 minutes lysing/breaking up adhesions to gain access to the rectal stump due to the multiple prior abdominal procedures). We want to keep this detail in mind once we find our CPT code because this is a good example of a case where modifier 22, significant, increased complexity, could apply. He then tells us he “located the rectal stump” and “opens the prior sutures” (so he is preparing the rectal stump for anastomosis). He doesn’t remove any of the remaining rectum, and that’s okay (he is not required to do so, but may choose to remove part of the rectum when circumstances warrant that). He then comes up to the abdominal wall and frees the colostomy from the abdominal wall all the way around. He then removes (aka resects) 15 cm of the colon (so that’s our intestinal resection). He makes sure he still has good length of colon to reach the rectum and brings the colon down into the abdomen where he lines it up with the rectal stump. The bolded portions here are key words that describe using tools such as staplers and anvils to bring the colon and the rectum back together (aka a colorectal anastomosis). He then checks for leaks (again no matter how they do that through water, air, a scope, etc. that is all part of the main procedure). The surgeon then closes the ostomy opening on the abdominal wall. So we have a takedown of a colostomy, resection of part of the colon, a colorectal anastomosis, and closure of the opening on the abdominal wall. These details support CPT 44626. Again, I would also add modifier 22 and diagnosis code K66.0 (postoperative adhesions of the intestine) due to the 90 extra minutes it took to gain access to the abdomen at the start of the case.

I hope the explanations and examples in this article help you code ostomy takedowns with confidence. If you have an example that wasn’t addressed in this article, please reach out in the comments section below.