Category: Article

In our last article, we addressed the differences between anal fissures and anal fistulas and some of the ways in which these two conditions might be treated by surgeons. We also looked at CPT codes for treatment of a fissure or a fistula by itself (when the surgeon is not treating any other conditions in the rectum/anus during the same surgery). If you have not had an opportunity to review Part 1 of this topic, I would encourage you to do so first as the terminology and definitions we covered will greatly help in understanding the rest of the information presented in this article: https://codingmastery.com/2020/02/02/distinguishing-anal-fissures-from-anal-fistulas/.

Today’s article will focus on CPT codes for treatment of anal fissures and fistulas along with other conditions in the rectum and anus at the same time and provide some example reports that will help you put everything you have learned together and code the treatment of these conditions with confidence.

Anal Fissure Treatment with Hemorrhoidectomy

• 46257: Hemorrhoidectomy, internal and external, single column/group; with fissurectomy
• 46261: Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fissurectomy

These CPT codes are reported when both an anal fissure is excised and hemorrhoids are excised during the same surgery. The code is chosen based on the number of columns/groups of hemorrhoids that are removed. If you need more information about determining the number of columns/groups removed in a hemorrhoidectomy procedure, check out our article about coding hemorrhoidectomy procedures (same principles will apply here with these combination codes): https://codingmastery.com/2018/12/01/successfully-master-coding-hemorrhoid-procedures/.

Anal Fistula Treatment with Hemorrhoidectomy

• 46258: Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed
• 46262: Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed

These CPT codes are reported when both an anal fistula is excised and hemorrhoids are excised during the same surgery. The code is again chosen based on the number of columns/groups of hemorrhoids that are removed. Notice that these codes also include a fissurectomy “when performed.” That means a fissurectomy is not required to use one of these codes, but you also should not report a fissurectomy separately in addition to these codes if one is performed because the work of performing that fissurectomy is already included in CPT codes 46258 and 46262.

Anal Fistula Treatment with Incision and Drainage

• 46060: Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of a seton.

This CPT code is reported when a specific type of rectal abscess is drained and an anal fistula is either excised or cut open during the same surgery. The specific type of abscess that must be drained to use this code is an ischiorectal abscess (an abscess that forms between the muscles that control the rectum and the pelvic bone) or an intramural abscess (an abscess that forms in the muscular layer of the rectal wall itself). Notice this code also includes placement of a seton when necessary. The phrase “with or without” in CPT means the same thing as “when performed” in code definitions. Therefore, a seton placement is not required to code CPT 46060, but you also wouldn’t code placement of a seton separately in addition to this code if a seton was placed because the work of performing that seton placement is already included in CPT 46060.

Okay now that we have our terminology and codes under our belts, time to put all this together with some chart examples.

Example #1: After sterile prep and drape, an exam under anesthesia was performed. This exam confirmed the presence of an anal fissure with significant inflammation of the surrounding tissue, constricting the anal sphincter. This finding was thought to account for the patient’s recent reports of constipation and significant pain with bowel movements.

Using the Bovie, heat was applied to the fissure and we scraped the tissue to expose the underlying healthy mucosa. We then placed a bougie and stretched the anal sphincter to allow better passage of stool.

The patient tolerated the procedure well. She will be discharged home with instructions to keep the area clean and dry and follow up in our office in 10 days.

Answer Example #1: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon confirms presence of an anal fissure during an exam under anesthesia. So a “fissure” is the pathology being treated in this case. He also mentions inflammation constricting (narrowing) the anal sphincter. Note that the exam under anesthesia mentioned is bundled to the anorectal procedures performed in this case per the NCCI guidelines.

In paragraph #2, he then tells us what he does to treat the fissure. He first applies heat with a Bovie. A Bovie is a specific type of cautery instrument and applying heat means the same thing as electrocautery. He then scrapes the tissue until healthy tissue is exposed underneath. Scraping is another term for curettage. So he is “destroying” the anal fissure with cautery and curettage. This documentation supports CPT 46940.

Rationale: I recommended CPT 46940 for “initial treatment” since no prior treatment is mentioned. Also the details about having to do an exam under anesthesia to confirm what is accounting for the patient’s symptoms and finding that fissure imply this is initial discovery of the fissure and, therefore, initial treatment as well.  Notice, the physician also mentions inserting a bougie (a type of dilator) and stretching/dilating the anal sphincter. Because CPT 46940 includes dilation of the anal sphincter “when performed,” we will not code an additional CPT code for the dilation (it is all part of CPT 46940).

Example 2: After sterile prep and drape, a circumferential anoscopy was performed which appeared to demonstrate internal tract openings in the anus, suspicious for an anal fistula. We then examined the anal opening and saw not one, but two distinct tracts externally. We then inserted a probe into each tract, one at a time, to determine the extent of these tracts. The first tract allowed the probe to pass all the way to the rectum, but the tract did not cross or violate either sphincter, confirming the presence of an extrasphincteric fistula. This tract was fairly small and did not appear to require excision. The second tract allowed passage of the probe to the space between the internal and external sphincters, supporting presence of an intersphincteric fistula. This tract was much more extensive and may require staged treatment.

Beginning with the extrasphincteric fistula, we incised the tract to allow adequate drainage. This concluded our procedure for this first fistula. We then shifted our attention to the much more extensive intersphincteric fistula. The tract was excised to the extent possible, taking care not to violate the sphincters. We then placed a seton to allow for ongoing drainage.

The patient tolerated the procedure well. Given the extent of the second anal fistula, he may require a staged excision or additional seton placement in the coming weeks. He was sent home with discharge instructions and will follow up in the office in 5 days to check status.

Answer Example 2: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon confirms presence of two distinct anal fistulas during his anoscopy and exam: an extrasphincteric and an intersphincteric fistula. Note that the anoscopy and exam under anesthesia mentioned at the start are bundled to the anorectal procedures performed in this case per the NCCI guidelines.

In paragraph #2, he then tells us what he does to treat the fistulas. He first incises the smaller extrasphincteric fistula (aka a fistulotomy) to allow for adequate drainage. No further work is required on this fistula so he shifts focus to the larger intersphincteric fistula.  For this fistula, he excises as much of the fistula tract as he can (aka a fistulectomy) while avoiding injury to the sphincters. He also places a seton. This documentation all together supports CPT 46280.

Rationale: You might initially be tempted to code 46275 for the intersphincteric fistula treatment and 46280 for the extrasphincteric fistula treatment since the term “intersphincteric” does not appear in the code description of CPT 46280. However, what does appear in the code description of CPT 46280 is that the code can be used to report treatment of “multiple fistulas.” Per the description of CPT 46280, those “multiple fistulas” may be treated by a fistulotomy, a fistulectomy, or both. Finally, the description of 46280 also states that this code “includes placement of a seton” when performed. So again the fistulotomy on the extrasphincteric fistula, the fistulectomy on the intersphincteric fistula, and the seton placement in the intersphincteric fistula tract all add up to CPT 46280 since all of that work is described by this one code.

Example 3: After sterile prep and drape, a circumferential anoscopy was performed which demonstrated thrombosed and prolapsing mixed hemorrhoids in the right anterior quadrant.  The external hemorrhoid was significantly enlarged due to thrombosis and was actively draining. While this was certainly a significant and somewhat unexpected finding, it does not completely account for the patient’s report of significant pain around the anal sphincter externally. Therefore, we continued our exam and discovered a deep fissure along the left side of the anal opening.

To completely treat these significant findings, we started by circumferentially cutting around the fissure, completely removing this deep groove. We packed the site carefully with sterile gauze to allow for drainage and prevent infection. We then shifted attention to the aforementioned hemorrhoids. The mixed hemorrhoid column was circumferentially excised and bleeding controlled with Bovie.

The patient tolerated the procedure well. We will see him in the office tomorrow to exchange packing material around the fissurectomy site and ensure adequate pain control.  

Answer Example 3: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon confirms presence of mixed hemorrhoids during an anoscopy. As we discussed in our hemorrhoidectomy article, mixed hemorrhoids are hemorrhoids with an internal and external component. These hemorrhoids in this case are in a single column/group in the right anterior quadrant. The surgeon then continues her exam based on the patient’s report of his symptoms and finds a deep anal fissure just outside the anal canal opening. Note that the anoscopy and exam under anesthesia mentioned at the start are bundled to the anorectal procedures performed in this case per the NCCI guidelines.

In paragraph #2, she then tells us what she does to treat the fissure and hemorrhoids. She first cuts all the way around the fissure and “removes the deep groove completely” (aka a fissurectomy).  She then goes back to the mixed hemorrhoids and completely excises this single column/group of hemorrhoids which again are internal and external. This documentation all together supports CPT 46257.

Rationale: Because we have a combination code that includes the work of a fissurectomy and excision of a single column/group of internal and external hemorrhoids, all of the work together is reported with CPT 46257. Note that it would be inappropriate to code 46255 (hemorrhoidectomy, internal and external, single column/group) and 46200 (fissurectomy) together instead of using the combination code 46257. Anytime you have a combination code available in CPT that accurately describes the work performed, you should report the combination code instead of two or more codes together to describe the individual procedures.

Example #4: After sterile prep and drape, a circumferential anoscopy was performed which confirmed internal/external hemorrhoids in the right anterior and right posterior positions. We also placed a sterile probe in a tract that began just beyond the anal opening and confirmed extension of that tract across the external sphincter and into the intersphincteric space, thus confirming the suspected transsphincteric fistula.

We began our procedure by lifting the anoderm and circumferential excising the hemorrhoids in the right anterior and right posterior locations. Bleeding was controlled with the Bovie and a couple of sutures placed at each excision site to prevent dehiscence of the tissue. Next we turned our attention to the fistula. We made an incision to open up the fistula tract and allow placement of a seton to facilitate continued drainage.

The patient tolerated the procedure well. He will follow up in the office in a week. If the seton placement and fistulotomy are successful, we will continue to monitor the healing course. If the patient remains symptomatic, he may require an additional surgery for fistulectomy or additional seton placement.

Answer Example #4: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon discovers internal and external hemorrhoids in two separate groups/columns (right anterior and right posterior). Next, he notices a tract near the anal opening and inserts a probe to see how far that tract extends and where that internal opening is located. He ultimately confirms a transsphincteric anal fistula. Note that the anoscopy mentioned is bundled to the anorectal procedures performed in this case per the NCCI guidelines.

In paragraph #2, he then tells us what he does to treat each condition. He first excises the two columns of hemorrhoids (hemorrhoidectomy, 2 or more columns or groups, internal and external hemorrhoids). We know this is an excision because we see him lifting/elevating the anoderm and “circumferentially excising” the hemorrhoids. He also places a couple of sutures but that is just to control bleeding and keep the tissue at the hemorrhoidectomy site closed (all part of the main procedure). Next, he shifts his focus to the anal fistula and cuts the tract open (fistulotomy) and inserts a seton. This documentation supports CPT 46260 and 46280 together.

Rationale: You might be tempted to code CPT 46262 since the physician is excising hemorrhoids and treating an anal fistula at the same time. But CPT 46262 requires a hemorrhoidectomy of 2 or more columns/groups and a fistulectomy. Here our surgeon performed a fistulotomy not a fistulectomy. For that reason, we would code 46260 for the hemorrhoidectomy of 2 or more internal/external columns/groups and 46280 for a fistulotomy of a transsphincteric fistula with a seton placement together to accurately code this surgery.

Colorectal cases and anorectal surgeries in particular are challenging to code due to the number of different code options and all of the little details that can impact which CPT code(s) would be important. I hope that the terminology and examples presented here help you to code these procedures with confidence. Happy coding!

Do anal fissures and anal fistulas cause you coding confusion? These two terms sound similar, but refer to different conditions. The treatment of these two conditions is also coded differently. Our article today is dedicated to helping you master the difference between anal fissures and fistulas so you can code the treatment of these conditions confidently.

The information we will cover in this article is very technical (lots of medical terms and anatomy to be familiar with). I’ve included some helpful definitions and links with pictures for those of you who are visual learners. It may take a couple of reads or some additional research (e.g., watching videos) to completely visualize and understand these procedures, but the information presented here should give you a great start.

• An anal fissure is a tear in the lining of the anus or rectum. These tears can occur for a variety of reason, but constipation and passing hard stools are common causes of anal fissures.
• An anal fistula is a tunnel/tract between the anus and the skin around the anus. Again anal fistulas have different causes, but one common cause is an old abscess that did not heal completely. There are many different types of fistulas that are usually named based on their location:

1. Intersphincteric: Inter means between and sphincteric refers to the muscles that control the opening and closing of the anus. There are two sphincters in the human body: one internal and one external. An intersphincteric fistula is one whose tract begins in between the internal and external sphincters and exits typically around the opening of the anus.
2. Extrasphincteric:  Extra means outside or beyond. An extrasphincteric fistula is one whose tract begins in the rectum or sigmoid colon and continues through the levator muscle and ends around the anus. This type of fistula does not involve the sphincters or the space between them, so it is “extra” or “outside” the sphincters.
3. Transsphincteric: Trans means across. A transsphincteric fistula is one whose tract begins in the space in between the internal and external sphincters or in the space behind the anus, comes through/across the external sphincter, and exits within a couple of inches of the anal opening.
4. Suprasphincteric: Supra means “above.” A suprasphincteric fistula is one which begins in the space between the internal and external sphincters and then passes above them (usually taking a route initially above and then through the puborectal muscle and then through the levator ani muscle to exit within a couple of inches of the anal opening).
5. Subcutaneous: This type of fistula sometimes referred to as a “superficial” fistula, is just underneath the surface of the mucosal lining of the rectum in the subcutaneous tissues. It does not involve the sphincters or the inter or suprasphincteric spaces and instead is a more superficial, low-lying fistula.
6. Second Stage: This last term, a “second stage” fistula is actually not referencing a location but a set of conditions under which a fistula is treated. Sometimes with extensive fistulas that involve the sphincters, the surgeon may have to address the problem in two separate operations by opening up/excising part of the fistula in the first operation (first stage) and then opening up/excising the rest of the fistula tract after some healing has occurred in the second operation (second stage).  

If you are more of a visual learner, check out these links which depict the different types of fistulas:

• The first link shows you the anatomy of the anus including the internal and external sphincters and the intersphincteric space (the space between the internal and external sphincters) so you can really visualize where these structures and spaces are located: Anatomy of the Anus
• The second link shows you lines along the anatomy of the anus that depicts the different locations of the fistulas defined above: Types of Anal Fistulas

Now that we have some important anatomy and terms under our belts, let’s start talking about how to code treatment of fissures and fistulas.

Step #1: The first step is to determine if the condition requiring surgery is an anal fissure or an anal fistula. This may sound obvious, but I have seen many times that these two conditions were confused for each other, resulting in a wrong CPT code. Hopefully the definitions above help you determine which condition is appropriate.

Step #2: The next step is to determine the type of surgical procedure performed to treat the condition. Here are some possibilities:

• Surgical Excision: The surgeon may “cut out” the fissure or the fistula tract to remove it completely or in part. When treating a fissure in this way, the surgery is called a fissurectomy. When treating an anal fistula in this way, the surgery is called a fistulectomy.

• Surgical Opening: The surgeon may “cut open” the diseased area to allow the area to drain and heal. This typically happens with a fistula but not a fissure so if a term ending in “otomy” is present in the report, that’s a good sign that you are looking at an anal fistula rather than an anal fissure.

• Closure with Glue: As strange as this may sound, there is a special glue that can be used to close more superficial fissures and fistulas in the anus. This glue is called fibrin glue.

• Closure with Flap: The surgeon may create a small flap of tissue from the surrounding tissue that can be rotated over the fissure or fistula to close it.

• Placement of a Seton: A seton is made of cotton or other absorbable tissue and is passed into the opening and left protruding outside it. The goal is for the fistula to heal around the seton. The seton can then be pulled out or may fall out on its own.

• Destruction: Using cautery (heat) or curettage (scraping) to destroy an anal fissure or fistula.

Below are the established CPT codes available for treatment of anal fissures and anal fistulas when performed as the only anorectal surgical procedure during the case.

.Anal Fissure Treatment

Destruction:

• 46940: Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial
• 46942: Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent

As you can see, there are two codes for “destruction” (i.e., cautery or curettage) of an anal fissure. You choose the code based on whether this is the initial treatment or if this is a subsequent treatment of the same fissure.

Excision

• 46200: Fissurectomy including sphincterotomy, when performed

This code is reported when the anal fissure is excised. A sphincterotomy (cutting the sphincter muscle to allow it to relax/stretch) may also be performed. The sphincterotomy is included in CPT 46200 when performed but is not required to code this CPT.  

Anal Fistula Treatment

Excision or Opening:

• 46270: Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous
• 46275: Surgical treatment of anal fistula (fistulectomy/fistulotomy); intersphincteric
• 46280: Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric, or multiple, including placement of a seton, when performed
• 46285: Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage

You will recognize a lot of the terms we have already discussed in these code descriptions.

• The first thing to notice is that all of these codes are for “surgical treatment” of the fistula which is defined as a fistulectomy, a fistulotomy, or both.
• The next thing to notice is that the location of the fistula (subcutaneous, intersphincteric, etc.) helps you choose the appropriate code.
• For CPT 46280, this code includes a seton placement “when performed.” So again, if the surgeon places a seton it is included in 46280, but it is not required in order to report this code. For all other types of fistulas not described in CPT 46280 (e.g., subcutaneous, intersphincteric, etc.), you may report both the code for the fistulectomy/fistulotomy plus code 46020 for placement of a seton when both procedures are performed.
• Also, CPT 46280 can be reported for a fistulectomy/fistulotomy of multiple fistulas regardless of what type of fistula is treated (i.e., if the surgeon treats both a transsphincteric and an intersphincteric fistula which would normally fall under different CPT codes when treated by themselves, they would be treating “multiple” fistulas which would be CPT 46280 alone.
• Finally, CPT 46285 is for a “second stage” procedure to treat any type of anal fistula. Again the second stage procedure would be for cases where the same fistula has already been treated partially in a prior procedure and the patient is brought back for a second procedure to complete surgical treatment of the fistula.

Closure with an Anal Flap:

• 46288: Closure of anal fistula with rectal advancement flap

This code is used to report treatment of any type of anal fistula that is closed/repaired with a rectal advancement flap.

Closure with Glue:

• 46706: Repair of anal fistula with fibrin glue

This code is used to report closure/repair of any type of anal fistula with glue. Notice that this code is in a totally different section of CPT than the rest of our anal fistula codes (467xx rather than 462xx). This code emphasizes the importance of good technique when searching for a CPT code (starting with an index search and then looking at the full description in the CPT manual).  This technique ensures you have looked at all of your options and applied the best CPT code to describe the procedure performed. If you went to the 462xx section of CPT alone to start your search, you would miss this code option.

The codes above are for treatment of anal fissures and fistulas by themselves. In our next article we will look at some combination codes that might apply when these conditions are treated along with other conditions of the rectum/anus such as abscesses and hemorrhoids. We will also look at some surgical coding examples to help illustrate how all of these codes might apply to different cases and help you master picking the correct CPT for your particular scenario.

If you code for a cardiologist, chances are you have coded your fair share of implantable cardiac defibrillator (ICD) and pacemaker lead removals. While these devices are amazing products available due to advances of modern medicine for patients with conditions such as rhythm disorders and heart failure, the leads and batteries in these devices, like any mechanical/electrical device, can breakdown over time. Therefore, it is common to perform procedures for the removal or replacement of these devices.

Before we look at some codes for lead removal and talk about laser lead extraction specifically which is the focus of our article today, let’s look at some terminology you need to know to separate the different code options. This background knowledge will help you when it comes to coding laser lead extractions.

• Pacemaker: An electronic device that regulates the rhythm of the heart. Pacemakers are placed in patients with electrical disturbances in the heart where the rhythm/rate of the heart is abnormal.
• Internal Cardiac Defibrillator (ICD): An electronic device capable of shocking and restarting the heart. These devices are most often placed in patients with heart failure.
• Transvenous: This word means “through or across a vein.” In the context of codes for pacer and ICD lead removal, if the code description states removal of “transvenous” electrodes/leads, the code is used to report removal of leads that were previously placed by accessing a vein such as the internal jugular or subclavian vein and then placing the leads through that vein and into the heart. In this way, you work “through the vein” to gain access to the heart with the leads.  
• Endocardial: “Within the heart.” In the context of pacer/ICD leads, this term refers to transvenous leads that are threaded through the access vein and then into the chamber(s) of the heart.
• Epicardial: “On the surface of the heart.” In the context of pacer/ICD leads, this term refers to leads that are placed by opening the chest through an incision and attaching the leads to the surface of the heart instead of placing the leads transvenously inside the chambers of the heart.
• Single Chamber: A pacemaker or ICD with leads in only one chamber of the heart (i.e., right atrium or right ventricle).
• Dual Chamber: A pacemaker or ICD with leads in two chambers of the heart (i.e., right atrium and right ventricle)
• Multi-Chamber or Biventricular: In the context of pacemakers and ICDs, either term refers to a device with leads in the right atrium, right ventricle, and left ventricle. Sometimes these devices have leads in the right ventricle and left ventricle only without a right atrial lead – that device is still considered “biventricular” since leads are in both ventricles.  

To code removal of leads from a pacemaker or an ICD device, you first need to determine which device the patient has and then look for the approach to removing the leads.

For Transvenous Pacemakers

• 33234: Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular
• 33235: Removal of transvenous pacemaker electrode(s); dual lead system

Coding tips: CPT codes 33234 and 33235 involve opening the pacemaker pocket; disconnecting the leads from the generator; and removing the transvenous leads by twisting, pulling, or putting traction on the leads to remove them.

Code CPT 33235 for removal of transvenous pacemaker electrodes through these methods when the patient has a dual lead (chamber) system (leads in both the right ventricle and the right atrium) whether leads are removed from the right atrium, the right ventricle, or both. The final code is not based on how many chambers from which leads are removed, but on how many chambers in which leads exist at the start of the case.

Also notice, there is no code for removal of “multi-lead” or “biventricular” pacemaker electrodes (where removal of a left ventricular lead(s) occurs in addition to removal of leads from the right atrium and/or right ventricle). Use the dual lead system code when biventricular pacemaker leads are removed through this approach.

• 33238: Removal of permanent pacemaker transvenous electrode(s) by thoracotomy

Coding tip: Code CPT 33238 when pacemaker leads were previously inserted tranvenously, but it is necessary to make an incision in the chest (thoracotomy or sternotomy) to remove the leads. This code is used whether a thoracotomy or a sternotomy approach is used. This open removal usually occurs when leads are surrounded by a lot of scar tissue and cannot be removed transvenously or there is concern for injury to the vena cava. Use this code regardless of the number of chambers in which pacemaker leads exist.

For Epicardial Pacemakers

• 33236: Removal of epicardial pacemaker and electrode(s) by thoracotomy; single lead system, atrial or ventricular
• 33237: Removal of epicardial pacemaker and electrode(s) by thoracotomy; dual lead system

Coding Tips: These codes are used when epicardial pacemaker leads are removed (pacemaker  leads on the surface of the heart). By definition, removing these devices requires the physician to make an incision into the chest (thoracotomy or sternotomy). These codes can be used for either a thoracotomy or sternotomy approach.

Also notice, there is no code for removal of “multi-lead” or “biventricular” pacemaker electrodes (where removal of a left ventricular lead(s) occurs in addition to removal of leads from the right atrium and/or right ventricle). Use the dual lead system code when biventricular pacemaker leads are removed through this approach.

The terms single and dual lead system have the same definitions as they do for transvenous pacemaker leads – use 33237 if removing lead(s) from a pacemaker with electrodes overlying the right atrium and right ventricle whether leads are removed from the surface of the right atrium, the right ventricle, or both.

Finally, these codes unlike 33234, 33235, and 33238 include removal of both the pacemaker generator and the epicardial lead(s). There is no code for removal of epicardial leads alone. In the rare case that epicardial leads are removed and the generator is not, consider adding modifier 52 to the appropriate code.

For Defibrillators:

• 33243: Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy
• 33244: Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction

Coding Tips: Unlike our pacemaker lead removal codes, there are not separate codes for removal of single or dual lead systems for implantable defibrillators. Instead there are two codes in total — 33243 for an open chest incision approach which can include removal of leads by thoracotomy or sternotomy and 33244 for transvenous removal which would involve the same methods described for transvenous pacemaker lead removal (pulling, twisting, or placing traction to remove the lead).  These codes are reported regardless of how many leads are removed and regardless of how many chambers in which leads exist.

Laser Lead Removal:

Now that we understand some key terminology and the codes in place in CPT to report removal of the leads of pacemaker and ICD devices, that brings us full circle to our topic of the day, “laser lead removal.”In a limited number of cases, the patient may have significant scar tissue that causes the lead(s) of the pacemaker or ICD system to become stuck to the wall of the vein into which it was inserted. When this occurs, you may see the cardiologist pass a laser sheath into the vein and use that laser to break up the scar tissue and free the lead(s) for removal. We’ve looked at the definitions of many different codes for removing leads of pacemaker and ICD devices, and none of them mention a laser so how is this laser extraction coded?

Per the AMA and professional physician societies, use the normal “transvenous extraction” codes we just discussed (33234/33235 for pacemakers or 33244 for ICDs) and consider adding modifier 22. Modifier 22 is for significant increased complexity and is designed to increase the billed and reimbursed amounts for a given code to reflect that the work involved in a particular procedure was significantly more complex than typical. The modifier in the context of a laser lead removal explains the increased work of removing transvenous lead(s) with a laser sheath. There is an increase in the time it takes to remove the leads as well as in the complexity of the procedure/risk to the patient when this much scar tissue is present. Crediting the modifier is the best way to give the physician credit for this increased work.

It is important to note that there is no separate CPT code for the laser. Coders should not apply an unlisted code with the transvenous code removal or try to use a code such as excision of foreign body from the vein (37197) as these codes do not accurately describe the procedure performed.

If you have been coding surgeries for awhile, you’ve likely seen the term “separate procedure” in some of the descriptions for the codes you use. Codes with the term “separate procedure” in their code descriptions are said to have a “separate procedure” designation in CPT (this is a phrase you may see in guidelines from the AMA and CMS). Even though this term has been used in CPT for many years, it is still a source of a lot of questions for coders and many inquiries I see on coding forums. Some people look at the term “separate” and think that a separate procedure is something that should always be reported separately (or in addition to) other codes on the claim. What the term “separate” in this phrase really means, though, is quite the opposite.

A “separate procedure” according to CPT guidelines is a procedure that is usually a routine part of completing a more comprehensive procedure. CPT states that you should not code a CPT with the terminology “separate procedure” in its code description when you are reporting a more extensive procedure that separate procedure is a part of. However, you can report a code with a “separate procedure” designation in its code description if it is 1) the only procedure performed and billed during that surgery or 2) is performed with other procedures that it is not a routine part of.

The NCCI Policy Manual, which is published by the Centers for Medicare and Medicaid Services (CMS), also contains guidelines regarding codes with a “separate procedure” designation in their description. In Chapter 1 of this manual in section J, the guidelines say that “If a CPT code descriptor includes the term separate procedure, the CPT code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the separate reporting of a separate procedure when performed with another procedure in an anatomically related region often through the same skin incision, orifice, or surgical approach.” The guidelines make it clear that you should not report a code with the terminology “separate procedure” in the code description when it is performed with a “related procedure.” They further define related procedures as those occurring through the same incision, orifice (e.g., nasal, oral, etc.), or surgical approach (e.g., through the same endoscope).

The guidelines in this same chapter and section also clarify when it would be appropriate to report a CPT code with a “separate procedure” designation along with another CPT code: “A CPT code with a separate procedure designation may be reported with another procedure if it is performed at a separate patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area, often through a separate skin incision, orifice, or surgical approach. Modifier 59 or a more specific modifier (e.g., anatomic modifier) may be appended to the separate procedure CPT code to indicate that it qualifies as a separately reportable service.” Before reporting a code with a “separate procedure” designation with another CPT code during the same surgery, look to see if the two procedures happen in anatomically unrelated areas and are completed through separate incisions or approaches.

To give an example, CPT 44005 is coded for lysis of adhesions. This is a surgical procedure where the surgeon creates an incision in the abdomen and breaks apart adhesions that have formed in the abdomen due to an infection or a prior surgery. CPT 44005 has a “separate procedure” designation in its description: Enterolysis, freeing of intestinal adhesions (separate procedure). Since CPT 44005 has the “separate procedure” designation, it would be appropriate to report this code in a couple of circumstances:

1) If lysis of adhesions was the only surgical procedure performed on that patient during that surgery, you can report CPT 44005 by itself. In this scenario, the lysis of adhesions was the planned procedure and the only procedure performed.

2) If lysis of adhesions is performed at one time during the day (e.g., 9:00 a.m.) and later that same day another abdominal procedure (e.g., a colectomy) is performed, you can report the lysis of adhesions in addition to the other abdominal procedure since the two occurred at different encounters.  Modifier 59 or XE (separate encounter) would be added to CPT 44005 to clarify that the two procedures happened during separate encounters.

3) If lysis of adhesions was performed along with another procedure somewhere else in the body during the same surgery (e.g., lysis of adhesions in the abdomen and removal of a cyst from the arm), you could report both codes. In this scenario, the lysis of adhesions is not a routine part of removing the cyst in the arm but is totally unrelated to that second procedure and performed in an “anatomically unrelated area” through a “separate incision.” Therefore, you can justify reporting CPT 44005 with another code even though it has a “separate procedure” designation.

The scenarios above clarify when you can report lysis of adhesions (a CPT code with a “separate procedure” designation). However, there are also many surgeries where you cannot report lysis of adhesions separately. Lysis of adhesions performed during any other abdominal procedure (e.g., a gastrectomy, colectomy, appendectomy, cholecystectomy, etc.) cannot be billed separately. The reason the lysis of adhesions bundles during any other abdominal procedure is because, to gain access to the abdominal organs such as the stomach, colon, appendix, gallbladder, etc., it is necessary to first break up the adhesions. Therefore, the lysis of adhesions in this scenario is a routine part of completing the more comprehensive procedure and would be bundled.

What “separate procedure” scenarios have you encountered? A key part of coding is networking with other coders and learning together. Please share your experiences and questions in the comments field below.

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.