Author: Kimberly Mansingh

A little while back, I wrote an article called “Coding Ostomy Takedowns with Ease.” I’ve heard from several coders since that time sharing how helpful that article was for them. If you haven’t had a chance to check it out and are interested in learning more about this topic, you can read my old article here: https://codingmastery.com/2019/10/09/code-ostomy-takedowns-with-ease/.

In the course of connecting with coders about ostomy takedowns, I’ve received some questions about when and how to code an ostomy revision. So this article is dedicated to revisiting the topic of ostomy coding and focused specifically on revision procedures.

Before we delve into some codes and examples, we first need to define a revision in the context of these procedures. An ostomy revision occurs when a previously created ostomy (i.e., colostomy or ileostomy) is surgically altered in some way, but the patient still leaves the OR with the same type of ostomy.

• If the ostomy is no longer functioning at the end of the case, that’s a takedown.
• If a totally new segment of intestine is brought up and fashioned into a different ostomy (e.g., colostomy is taken down, but new ileostomy is created), that is a new ostomy creation not a revision.

Hopefully that helps to give a clear picture of what an ostomy revision should look like and also what it’s not.  From there, we have some additional details we need to determine to code our ostomy revision. Let’s look at the list of available CPT codes to figure out what details we need to find in the report:

44312: Revision of ileostomy; simple (release of superficial scar) (separate procedure)

44314: Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure)

44340: Revision of colostomy; simple (release of superficial scar) (separate procedure)

44345: Revision of colostomy; complicated (reconstruction in-depth) (separate procedure)

44346: Revision of colostomy; with repair of paracolostomy hernia (separate procedure)

As you can see, we have two possible codes for revision of an ileostomy and three possible codes for revision of a colostomy. So the first thing we need to determine in the operative report is whether the ostomy is formed from the ileum (the last segment of the small intestine) or some part of the colon. This detail is usually pretty clear in the operative report. The surgeon will generally use the terms ileostomy or colostomy directly or mention releasing the ileum or colon from the abdominal wall to begin the revision. But it is important to be aware of the different codes available for these procedures so you start off on the right foot with your coding.

Next, you can see we have codes for “simple” revision and codes for a complicated revision (or “reconstruction in-depth”). When it comes to colostomy revision, we have a third choice of “with repair of a paracolostomy hernia” which is a special scenario we will save for last. So we now need to determine if the revision is simple or complicated, but how exactly does CPT define these terms for ostomy revisions?

For a simple revision, we have a parenthetical statement “release of superficial scar” in the CPT code description. This would involve lysis of adhesions/scar tissue that may be pressing on the end of the ostomy and causing it not to function properly. That is definitely one example of a simple revision. The lay description for CPT 44312 and 44340 also provide some insight to other simple revision techniques which can include dissecting down through all layers of the abdominal wall and into the peritoneal cavity to free up the end of the stoma. A simple revision may also involve resecting the very end of the stoma and then reconnecting the remaining intestine/colon to the same ostomy opening in the abdominal wall.

For a complicated revision, the CPT code description is not as clear so, again, looking at the lay description from the Coder’s Desk Reference or your electronic coding software equivalent is a good place to get more details about what is included in these procedures. In an in-depth reconstruction, the expectation is that a larger segment of bowel will be removed (not just the end of the stoma removed/freshened up). Think of this more as a partial colectomy or partial intestine removal. The stoma may also be reconstructed or relocated to a totally new place on the abdominal wall which could require a separate incision on the abdominal wall to create the new ostomy.

Finally, as mentioned, for colostomies, you have a third option with CPT 44346 which states “with repair of a paracolostomy hernia.” In this procedure, a hernia has formed in the abdominal wall around the end of the stoma which can again cause the ostomy not to function correctly. The surgeon will make an incision over the site of the hernia and repair the defect. They may do that with sutures (sometimes called a primary repair), or they may insert a piece of mesh depending on the size of the defect. The surgeon may just free/mobilize the stoma at the ostomy site to repair the hernia, or he may move the stoma to a totally new ostomy site on the abdominal wall. Either way, you would report CPT 44346 for this procedure.¹

Let’s look at a couple of examples together and solidify how to code these procedures.

Example #1: After sterile prep and drape and protection of the existing colostomy, a midline incision was made and entry gained into the peritoneal cavity. The stoma was freed and mobilized from its attachment to the abdominal wall. We immediately noted about 12 cm of dusky intestine that was not viable, and likely the reason the old ostomy had not been functioning properly. This area of intestine was resected until we reached healthy bowel with adequate blood flow. The remaining colon was then brought back to the abdominal wall, everted, and refashioned into a stoma. A colostomy bag was applied. The midline incision was then closed in layers. Patient was transported to recovery in stable condition.

Answer Example #1: The bolded portions of the operative note are keys to selecting the correct CPT code. First, we see this is a colostomy so right away, we can rule out codes 44312 and 44314 for ileostomy revision. Next, we see that an abdominal incision is made to open the abdominal cavity and “12 cm of dusky intestine that was not viable” is noted. The surgeon then removes this entire section of non-viable bowel. Then taking the remaining colon after the dusky bowel was removed, he brings the colon back to the same ostomy site on the abdominal wall, everts it, and fashions a new stoma. The colostomy bag is then applied so we know a colostomy is still in place. In this case, they excise a significant area of non-viable colon and then recreate (reconstruct) the ostomy on the abdominal wall with the remaining colon. This is more work than a simple revision with release of the stoma, removing or freshening up the very end of the stoma, and then re-suturing. In this case, we will code CPT 44345 for a colostomy revision with in-depth reconstruction.

Example #2: A circumferential incision was made around the end of the existing ileostomy. Immediately significant scar tissue was encountered. We dissected down through the fascia and muscle layers of the abdominal wall and made entry into the peritoneal cavity. The scar tissue around the ostomy opening was lysed in its entirety. We then reconnected the ileum to the ostomy site using retention sutures.  Small bites of tissue at the end of the stoma were resected to ensure optimal functionality. The patient tolerated the procedure well and was transported to recovery with a new ileostomy bag.

Answer Example #2: The bolded portions of the operative note are keys to selecting the correct CPT code. First, we see this is a ileostomy so right away, we can rule out codes 44340, 44345, and 44346 for colostomy revision. Next, we see that an abdominal incision is made around the ostomy opening and “significant scar tissue” is noted. The surgeon then frees the stoma from the ostomy site on the abdominal wall. To do so, he has to dissect through all layers of the abdominal wall and into the peritoneal cavity. He lyses (or cuts through) all the scar tissue around the existing ostomy site. He then brings the end of the same segment of ileum back up through the ostomy opening and places some retention sutures. A small resection of just the end of the stoma (termed as “small bites of tissue” being removed) occurs. He then refashions the stoma and applies a new ileostomy bag. Because we have lysis of scar tissue and removal of just a very small amount of tissue at the end of the stoma, this is a simple revision, and we will code CPT 44312.

I hope these tips help you while coding ostomy revision cases. Do you have a unique ileostomy or colostomy revision case? Drop your operative report without patient information in the comments below, and I will be happy to review it with you and post a response with the proper coding for anyone who may have the same question.

References:

1- CPT Assistant, December 2009, copyright American Medical Association

Q. My surgeon removed old screws and rods at L2-L3. He then performed a new posterolateral fusion where he inserted new screws and rods at L2, L3, and L4 during the same operation. Should we code this as replacement of spinal hardware (CPT 22849)? Is the removal of the old screws and rods coded separately with CPT 22850?

A. Actually, in this case, you would report the new instrumentation code 22842 only. We would select this code since the approach is posterior (instrumentation placed during a posterolateral fusion), and hardware is segmental and spanning 3 segments (L2, L3, and L4). If you need additional information on how to determine if hardware is segmental or non-segmental, you can check out a recent article on that topic here: https://codingmastery.com/2021/09/28/segmental-vs-non-segmental-spinal-instrumentation-cpt-codes-22840-22848/.

To explain why we would code only the new insertion code, CPT 22849 for reinsertion of a spinal fixation device is reported when the exact same hardware is removed and replaced at the same levels (e.g., broken screw is removed at L2, and a new screw is inserted at L2).¹ In this scenario, though, screws and rods are removed at L2-L3 and then new screws and rods are placed at L2, L3, and L4. L4 was not included in the original surgery so this is an extension of that original hardware. For that reason, this is not a true reinsertion as defined in CPT 22849.

Regarding the hardware removal, in addition to having NCCI edits that bundle CPT 22850 to 22842 and other new instrumentation codes, the CPT manual states this: “Only the appropriate insertion code (22840-22848) should be reported when previously placed spinal instrumentation is being removed or revised during the same session where new instrumentation is inserted at levels including all or part of the previously instrumented segments. Do not report the reinsertion (22849) or removal (22850, 22852, 22855) procedures in addition to the insertion of the new instrumentation (22840-22848).”² Because the new instrumentation is inserted at L2 and L3 which were included in the previously instrumented segments and then extended to L4 as well, following this guideline, we will code only CPT 22842.

1 – CPT Assistant, June 2017, copyright American Medical Association

2 – CPT Professional 2021, copyright American Medical Association, 2020