Q. During an open repair of a colovesical fistula, repair of the fistula required excision of the sigmoid colon. The remaining colon was then anastomosed to the rectum (i.e., a low anterior resection was performed). Should the low anterior resection (CPT 44145) be coded in addition to the colovesical fistula repair (CPT 44661)?
A. No, the removal of the colon and the anastomosis needed to reconnect the remaining colon and the rectum is included in the colovesical fistula repair. A fistula is an abnormal connection between two organs/structures. Sometimes closing that abnormal connection requires removal of part of the organ(s) on either end of that abnormal connection. When this excision and repair of organs is needed to close the fistula, this work is included in the fistula repair code. We have a couple of guidelines that can help us code this scenario correctly.
The NCCI Policy Manual, Chapter 6, section E.12 states this:
If closure of a fistula requires excision of a portion of an organ into which the fistula passes, excision of that tissue shall not be reported separately. For example, if closure of an enterocolic fistula requires removal of a portion of adjacent small intestinal tissue and a portion of adjacent colonic tissue, closure of the enterocolic fistula (CPT code 44650) includes the removal of the small and large intestinal tissue. The excision of the small intestinal or colonic tissue shall not be reported separately.
The lay description of CPT 44661 also includes the work of removing part of the organs into which the fistula passes and reconstructing those organs (which would include an anastomosis of the colon/rectum). This makes sense because when part of an organ is removed, you must repair the part of the organ that remains in some manner to allow that organ to continue functioning as intended (e.g., an anastomosis, suture repair, patch closure, etc.):
Lay Description of CPT 44661: In 44661, resection of the bladder and/or intestine is required. The fistulous tract between the bowel and bladder is severed. The bowel is clamped above and below the fistulous tract, transected, and the portion containing the fistulous tract removed. An end-to-end anastomosis is then used to reapproximate the bowel. If the bladder requires resection, the fistulous tract is excised along with a portion of the surrounding bladder. The remaining bladder wall is then reapproximated with sutures.
Based on those guidelines, we would not report 44145 separately in this scenario because the excision of the intestine involved with the fistula and the anastomosis is already included in the code 44661.
Notice in the guidelines from the NCCI Policy Manual that this guideline does not just apply to a colovesical fistula. It could apply to an enterocolic fistula (fistula between the small and large bowel), an enterocutaneous fistula (fistula between the small bowel and the skin), a rectovaginal fistula (fistula between the rectum and vagina), or any other abnormal fistulous connection that may be present in the body. It would only be appropriate to report removal/repair of organs separately if they were at a site completely unrelated to the fistula and not removed/repaired as part of closing the fistula.
Let’s take a look at a couple examples to apply these guidelines.
Example #1: After sterile prep and drape, a generous midline incision was made and the peritoneum opened and carefully explored. We discovered a fistulous connection between the ileum and a loop of the ascending colon.We carefully developed a plane between these two structures, separating the small and large intestine at the level of the fistula.We discovered significant defects in both the ileum and the ascending colon. Starting with the ileum, we made a cut circumferentially just above the defect. Then coming down the colon, we carefully cut the ascending colon just beyond the defect and inferior to the hepatic flexure. We then brought the ends of the remaining ileum and colon together, and fired the stapler, creating an intact anastomosis.We irrigated with saline and ensured the anastomosis was intact. Once confirmed, we carefully closed the abdominal wall in layers.
Answer Example #1: The bold portions of the note are keys to appropriate code selection. First we can confirm the open approach with the “generous midline incision.” Next, we see that the surgeon is addressing a fistulous connection (or an abnormal connection) between the ileum (the last segment of the small intestine) and the colon. That makes this fistula an enterocolic fistula. We then see the surgeon separate the small and large intestine from each other which is the start of repairing the fistula. He then realizes that there are defects in both organs from the fistula that will require removal of part of the intestine. He makes a cut on either side of the defect in the small intestine and large intestine – the segment of the small and large intestine between those cuts is removed. Finally, he reconnects the remaining small intestine and colon together and checks to make sure his anastomosis is intact. We will code CPT 44650 for the enterocolic fistula repair. We will not report CPT 44160 separately for removal of the small and large intestine and subsequent anastomosis because this work was necessary to repair the fistula.
Example #2: After sterile prep and drape, a generous midline incision was made and the peritoneum opened and carefully explored. We discovered a fistulous connection between the ileum and a loop of the ascending colon.We carefully developed a plane between these two structures, separating the small and large intestine at the level of the fistula.We discovered significant defects in both the ileum and the ascending colon. Starting with the ileum, we made a cut circumferentially just above the defect. Then coming down the colon, we carefully cut the ascending colon just beyond the defect and inferior to the hepatic flexure. We then brought the ends of the remaining ileum and colon together, and fired the stapler, creating an intact anastomosis.On inspection, we also noticed an area of significant diverticular disease in the sigmoid colon. The colon was very distended and inflamed raising concern about the risk of perforation if we left this finding unaddressed. Therefore, we brought the stapler to the left side of the colon and fired the stapler above and below this area of diverticular disease, being careful to take the minimum amount of intestine necessary to ensure clean margins. We then carefully closed the stump of the remaining sigmoid colon and brought the end of the remaining descending colon up to the lower left abdominal wall. We then created an opening and fashioned a stoma. A colostomy bag was applied. This was necessary to protect the integrity of our anastomoses. We irrigated with saline and carefully closed the abdominal wall in layers. We will carefully follow the patient in our office and bring him back to the OR for takedown of his colostomy when appropriate healing has occurred.
Answer Example #2: Once again, the bolded portions of the note are keys to appropriate code selection. The first part of the operation is exactly the same as example #1 (so we will code CPT 44650 for that part of the operation, and the removal of the ileum and ascending colon as well as that first anastomosis are included in CPT 44650). However, in this second example, we now see a different problem (diverticular disease) in a different part of the colon (in the sigmoid colon). The sigmoid colon is located on the left side of the colon while the ascending colon is on the right so these are two separate anatomic locations in the colon. If you are a visual learner, check out this link with a picture of the anatomy of the colon to visualize where the surgeon is working: http://images.medicinenet.com/images/illustrations/2011-colon.jpg. After removing the sigmoid colon, the surgeon then closes the stump of the remaining sigmoid colon (i.e., he creates a Hartman’s pouch). He then brings the end of the remaining descending colon up to the abdominal wall and creates a stoma (this portion of the note describes creation of a colostomy). This additional work on the left side in the sigmoid colon is not part of the fistula repair – the sigmoid colon is not removed to facilitate repair of the fistula. So we get to report this work separately. Putting all the details together, we have an open approach, removal of part of the colon, and creation of a Hartman’s pouch with a colostomy: CPT 44143. So all together, this case would be coded with CPT 44650 and CPT 44143.
Resources:
NCCI Policy Manual, Chapter 6: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
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