Author: Kimberly Mansingh

Q.  Can you explain the difference between CPT codes 44140 and 44160? Both codes represent a partial colectomy, and I am unclear on what work must be performed after the colectomy to choose between the two codes.

A. These two codes often generate confusion for surgical coders. The confusion usually stems from uncertainty about what the term “ileocolostomy” which appears in the description of CPT 44160 means and what part of the bowel is removed in each procedure. Before we break down the definitions of both codes, if you are a visual learner and want a refresher on the anatomy of the colon, check out this image: Segments of the Colon Explained.

• CPT 44140 includes a partial colectomy with an anastomosis (reconnection) of two ends of remaining colon in the body. The anastomosis created during this procedure is a “colo-colonic” (or colon to colon anastomosis). For example, if a laparotomy incision is made and part of the ascending colon and the transverse colon are removed followed by an anastomosis between the remaining ends of the ascending and transverse colon, CPT 44140 should be coded. The same would be true for an open approach with partial removal of any part of the colon followed by anastomosis of the remaining two ends of the colon (e.g., removal of the descending colon with anastomosis between the sigmoid and the transverse colon, removal of the transverse colon and ascending colon with anastomosis of the cecum and the descending colon, etc.).
• CPT 44160 on the other hand represents excision of part of the colon and excision of the terminal ileum (the end of the last segment of the small intestine) followed by an ileocolostomy. The term ileocolostomy is often confusing because in other colectomy codes where we see a term ending in “-ostomy,” (colostomy, ileostomy, etc.), the “ostomy” refers to bringing the remaining end of the colon up to an opening created in the abdominal wall. A bag is then attached and feces leave the body through that artificial opening. At the end of the day, though, the suffix “-ostomy” simply means to “create an opening” or to “create a new connection.” So the term ileocolostomy means “to create a new connection between the ileum and the colon.” When we look at the description of CPT 44160 with this new understanding, the procedure represented by this code becomes clearer. To code CPT 44160, the documentation must support 1) removal of part of the colon, 2) removal of the terminal ileum, and 3) an anastomosis (new connection) between the remaining ileum and the remaining colon. For example, if a laparotomy incision is made, the terminal ileum and cecum are removed, and the ascending colon and the remaining ileum are anastomosed, CPT 44160 should be coded. Again this code is appropriate when any part of the colon and terminal ileum are removed through an open approach and an ileocolonic anastomosis (aka an ileocolostomy) is created (e.g., terminal ileum, cecum, ascending, and part of the transverse colon are all removed and remaining transverse colon and ileum are anastomosed).

For those of you coding laparoscopic colectomies, the same explanation provided above for CPT 44140 and 44160 also applies to CPT codes 44204 and 44205 in the laparoscopic world. CPT 44204 is for a laparoscopic approach with removal of part of the colon and a colocolonic anastomosis while CPT 44205 is for a laparoscopic approach with removal of part of the colon and the terminal ileum followed by an ileocolostomy.

Understanding terminology and anatomy are key to coding surgeries accurately.

Q: If a surgeon performs a series of laparotomies where they leave the incision open at the end of the case, requiring a return to the OR for a repeat laparotomy, do I need to append modifier 52 to the laparotomy codes? For example, would I code CPT 49000.52 for the first operation where the abdomen was not closed, and then 49002.58.52 for the second surgery since the wound is already open at the beginning of the second procedure, and there is no incision to open the abdomen?

A: While omission of a core element of a procedure clearly requires use of modifier 52 (e.g., a partial colectomy without anastomosis or diversion through an ostomy would require modifier 52), modifier 52 application for omission of opening or closing the surgical incision alone is a gray area in my view.

On one hand, you could argue that the laparotomy service is reduced in staged laparotomies since opening and closing the abdomen is part of the RVUs valued into the codes, and the surgeon did not complete the typical work. However, when deciding whether to apply modifier 52, it is important to review all documentation and to weigh the definition and impact of modifier 52 on the claim to determine if what is described supports a reduced service modifier.

Medicare defines modifier 52 as appropriate for use in cases where the “the service performed was significantly less than usually required.” A link to a Modifier 52 fact sheet from one of the Medicare Administrative Contractors is included here to support that definition: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144533. Based on this definition, insurance companies often reduce the typical reimbursement for a surgery by 50% when modifier 52 is applied, anticipating that “significant reduction” in typical work or intensity of the service. But does the serial laparotomy scenario meet this definition and warrant this kind of reduction? Not always, in my view.

In many cases where definitive, primary closure does not occur, the surgeon is typically closing the abdomen in some manner (e.g., applying temporary dressings or suturing the skin closed without closing all the underlying layers since they will reopen in a day or two when they return the patient to the OR). In these cases, I would argue that there is still surgical work that supports those RVUs for closure and the surgical work is “not significantly reduced.”

Additionally, I have seen cases where a surgeon leaves the patient open, resulting in serial laparotomies, where other aspects of the case could increase complexity. Examples may include extensive lysis of adhesions, an unstable trauma patient who needs a damage control operation now and definitive procedures later, or septic patients that are difficult to manage and stabilize during surgery. In these scenarios, you could almost argue a 22 modifier for increased complexity for some portions of the case. My perspective is that these portions that support increased complexity offset the portion that might warrant reduced services for not formally closing or opening the abdomen.

Finally, when it comes to reopening a recent laparotomy (CPT 49002), we typically assign this code following a recent laparotomy. The lay description for this procedure indicates that the laparotomy site is “opened and re-explored.” Opening and re-exploring could involve removing sutures or staples or dismantling temporary dressings to gain access into the abdominal cavity rather than creating an incision. These alterations to how the surgeon opens the abdomen would be typical in the setting of a  recent laparotomy and would not significantly reduce the work or intensity of the service expected for CPT 49002.

With that said, personally, I do not automatically recommend modifier 52 if a formal, primary closure of the abdomen or creation of an incision to reopen the abdomen in the second, staged surgery is the only omitted element for that procedure. Again, I weigh the overall documentation and look for surgical work that might support that the typical work or even increased work for the laparotomy procedure, avoiding use of modifier 52, unless there is a significant reduction in service that warrants the resulting anticipated reduction in reimbursement.