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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 its most basic level, 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., the terminal ileum, cecum, ascending, and part of the transverse colon are all removed and the 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 the terminology in the code descriptions as well as the anatomy of the colon and the small intestine are keys to coding surgeries these surgeries accurately.

If you are working in a specialty where you find yourself coding fat or fascia grafts regularly, you might be asking yourself “What happened to CPT 20926?”

Prior to 1/1/2020, CPT 20926 was used for transfer of tissue from one part of the body to another when we did not have a more specific code for that graft in CPT. This left coders and physicians using CPT 20926 to represent many different types of services – anything from liposuction to obtain some fat that was injected into the breast as part of a reconstruction to surgically excising a layer of temporal fascia which was inserted to repair the ear drum in a tympanoplasty procedure. The AMA reviewed CPT 20926 and its various uses last year and realized that this code was representing many different procedures all involving various anatomic sites and different amounts of clinical work to harvest the graft. As a result, they determined that the different types of grafts being reported with CPT 20926 should be better defined.

As of 1/1/20, CPT 20926 has been deleted. While you might be tempted to look for it’s replacement in the same section of CPT, the AMA has actually added 5 new codes to the Integumentary Section of the CPT manual (. The codes are distinguished by the method of obtaining the graft (direct excision vs. liposuction), the anatomic site where the graft is placed, and the amount of fat injected when applicable for the type of graft. Here is an overview of the new codes:

• CPT 15769: Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia)

• CPT 15771: Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms and/or legs; 50 cc or less of injectate
• + CPT 15772: Each additional 50 cc or part thereof (list separately in addition to code for primary procedure)
• CPT 15773: Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands and/or feet; 25 cc or less of injectate
  + CPT 15774: Each additional 25 cc or part thereof (list separately in addition to code for primary procedure)

As you can see, CPT 15769 is coded for “any autologous graft” (such as fat, fascia, etc.) where the graft is taken from the donor site by direct incision. The term autologous means “from the patient’s own body” so this type of graft is taken from one site in a patient’s body and implanted in another. Direct excision as the name implies, means they are making an incision and excising a piece/sheet of tissue. To give an example, that temporalis fascia graft for a tympanoplasty when harvested through a separate incision would be coded with CPT 15769 for “direct excision.”

In contrast, if autologous fat is harvested by liposuction technique (where a needle is inserted and fat cells withdrawn and prepared for injection in another site in the body), you need to look at codes 15771-15774. To pick the right code(s), you first need to identify the recipient site (where the graft is going). The anatomic sites listed in the code descriptions are recipient sites not donor sites (where the graft came from). You then need to determine how many cc’s of fat are being injected.

• If fat is injected into more than one anatomic site, but those recipient sites are listed under the same code (e.g., breast and scalp), add the total cc’s injected into all sites together to start coding.
• If fat is injected into more than one anatomic site, but those sites fall under different codes (e.g., breast and lips), add the total cc’s for the sites under the same code description together and add the total cc’s for the sites under a different code description together and assign separate codes.
• Notice the terminology “or part thereof” in the add on codes. That means that the total amount of cc’s injected does not need to be equally divided by 50 or 25 – you can assign an additional unit of 15772 or 15774 once the total cc’s of fat injected exceed 50 or 25 cc in total respectively.

Example #1: Fat is harvested from the abdomen by liposuction technique. The fat cells are prepared for injection. 150 cc are injected into the right breast, 30 cc into the left breast, and 80 cc into the left forearm.

Answer example #1: Since the breast and the arm are both recipient sites listed in codes 15771/15772, we will add the amount of fat injected at all sites together to start coding. So 150+30+80 = 260 cc in total. From there, we will report CPT 15771 x1 for the first 50 cc. We will then subtract 50 from 260, and we will have 210 cc left to report. This would be coded with CPT 15772 x 5. Again we are coding 1 unit of 15772 for “each additional 50 cc or part thereof.” 50+50+50+50 is 200 cc which is the first 4 units of 15772, and then we have a “part thereof” – 10 cc- leftover. We add the 5th unit of 15772, and our final coding is 15771 x1 and 15772 x5.

Example #2: Fat is harvested from the abdomen by liposuction technique. The fat cells are prepared for injection. 100 cc are injected into the left breast, 60 cc into the scalp, and 30 cc into the lips and 20 cc into the eyelids.

Answer example #2: Since the breast and the scalp are both recipient sites listed in codes 15771/15772, we will add the amount of fat injected at those sites together to start coding. So 100+60 = 160 cc in total. The lips and the eyelids are both recipient sites listed in codes 15773/15774 so we will add the amount of fat injected into those sites together. So 30+20 = 50 cc in total. Our 160 cc and 50 cc will not be added together since these recipient sites fall under different codes. From there, we will report CPT 15771 x1 for the first 50 cc of fat injected into the breast/scalp. We will then subtract 50 from 160 and have 110 cc left to report. This would be coded with CPT 15772 x 3. Again we are coding 1 unit of 15772 for “each additional 50 cc or part thereof.” We will then report 15773 x1 for the first 25 cc of fat injected into the lips/eyelids. We will subtract 25 from 50 and have 25 cc left to report. This will be coded with 15774 x1 for “each additional 25 cc or part thereof.”

Final coding: 15771 x1, 15772 x3, 15773 x1, 15774 x1

We will dedicate our next few posts to explaining some of the more notable changes to CPT for 2019.

Some changes that may impact physicians in a variety of specialties are the revisions to the existing PICC line codes and the addition of two new combination codes to capture PICC lines placed with imaging guidance.

A PICC line is a “peripherally inserted central catheter.” These vascular lines are often inserted in patients who require chemotherapy, IV antibiotics, or supplemental nutrition. CPT states that a vascular line is a PICC line when it is inserted in a peripheral vein (e.g., basilic, cephalic, or saphenous vein) and when it terminates in a central vein (i.e., subclavian vein, brachiocephalic (innominate) veins, iliac veins, the superior or inferior vena cava, or the right atrium)..

Revised Codes

CPT 36568 and 36569 have been revised to indicate that they represent a PICC line insertion without imaging guidance.

CPT 36568 is still reported for a patient younger than 5 years old while CPT 36569 is reported for a PICC line placement in a patient 5 or older.

Codes 36568 and 36569 are reported when no imaging guidance is used to place the PICC line (meaning no guidance is used to identify and/or enter potential venous access sites and no guidance is used to confirm the final position of the PICC line).

CPT 36584 was also revised. This code is used for complete replacement of a PICC line through the same venous access. For example, if a PICC line is already in place from a right basilic access and that line is removed and replaced with a new PICC line also placed via the right basilic vein, the PICC line is replaced “through the same venous access.” CPT 36584 was revised this year to indicate that it includes replacement of a PICC line through the same venous access with imaging guidance. The imaging guidance included in this code is used both to identify potential venous access sites and to confirm the final termination point for the PICC line. If imaging guidance is used to identify the potential access site (e.g., ultrasound guidance is used to identify the basilic vein, confirm it is patent and gain access into the vein), but imaging guidance is not used to confirm the final catheter termination point (e.g., the physician placing the PICC line orders a post op chest x-ray to confirm the catheter termination point and that x-ray is read by a radiologist not by the surgeon placing the PICC line), report CPT 36584 with modifier 52.
We are reporting modifier 52 because the same physician has not completed all of the work described by the code unless he continues to use imaging guidance throughout the procedure and confirms the catheter’s final termination point with imaging guidance.

The CPT guidelines were also updated to indicate that a PICC line replacement through the same venous access without any imaging guidance, is now reported with unlisted CPT code 37799.

New Codes

CPT 36572 and 36573 are brand new codes published this year to report placement of a PICC line with imaging guidance.

Like CPT codes 36568 and 36569, these new codes are differentiated based on the age of the patient receiving the PICC line. CPT 36572 is reported for insertion of a PICC line with imaging guidance for a patient younger than 5 years old and CPT 36573 is reported for insertion of a PICC line with imaging guidance for a patient 5 or older.

The imaging guidance included in CPT codes 36572 and 36573 is imaging guidance to identify and/or enter potential venous access sites and imaging guidance to confirm the final termination point of the PICC line. As with CPT 36584, if imaging guidance is used to identify potential access sites (e.g., fluoroscopic guidance is used to identify the cephalic vein, confirm it is patent, and enter the vessel), but imaging guidance is not used to confirm the catheter’s final termination point (e.g., the physician placing the PICC line orders a post op chest x-ray to confirm the catheter’s final termination point, and that x-ray is read by a radiologist not by the physician placing the PICC line), report CPT code 36572 or 36573 with modifier 52. Again, we are reporting modifier 52 because the same physician has not completed all of the work described by the code unless he continues to use imaging guidance throughout the procedure and confirms the catheter’s final termination point with imaging guidance.

Key Guidelines:

Because CPT codes 36572, 36573, and 36584 all include imaging guidance in their descriptions, you can no longer report imaging guidance codes such as 77001 or 76937 with these codes (these codes are combination codes that include the work of placing the PICC line as well as the imaging guidance necessary to place the line). It would also not be appropriate to report imaging guidance codes such as 77001 or 76937 with 36568 or 36569 since there is now a combination code to report insertion of a PICC line with imaging guidance.

Another rule to keep in mind is that when ultrasound is used to place a PICC line, the same documentation guidelines that apply to CPT 76937 also apply to these new combination codes. Documentation for ultrasound guidance must include 1) assessing patency of the potential access site(s) with the ultrasound (and noting any obstruction of the vessel(s) where appropriate); 2) entering the vessel under real-time ultrasound visualization; and 3) permanently storing the ultrasound images.

I hope these guidelines are helpful to you as you code PICC lines in the coming year. We will continue to cover some of the key 2019 CPT updates over the next couple of weeks to keep you informed of changes that may impact your daily work.