Colon and Rectal Surgery

Lyndia Carroll-Smith, CPC, CGSC

“

“As a Colon and Rectal Physician, I

worked my way up from the bottom”

What is Colon and Rectal Surgery

• Colon and rectal surgery is the sub-specialty of General

surgery where the treatment is primarily focused on the

disorders of the colon, rectum, and anus

• Surgeons in this field are often referred to as Proctologist.

(procto is a combining form meaning anus or rectum)

Colon and Rectal Disorders

Colon and rectal surgeons have expertise in treating :

• Cancer of small bowel, intestine – C17 (4th)

• Cancer of colon, large bowel – C18 (4th)

• Cancer of rectum – C20

• Cancer of anus and anal canal – C21 (4th)

Colon and Rectal Disorders Cont…

• Polyps

Non-adenomatous or Hyperplastic

Colon - K53.5

Anus – K62.0

Rectal – K62. 1

Adenomatous – D12(4th)

Small Intestine – D13.3 – D13.3(5th)

Colon and Rectal Disorders Cont…

• Inflammatory Bowel Disease (IBS), such as Crohn’s and

Ulcerative Colitis (K50 – K52)

• Diverticular disease K57(4th and 5th digit)

• Hemorrhoids – K64(4th)

• Fistula – K61(4th) and fissure – K60(4th)

• Motility issues such as constipation, IBS (K58 – K59.9)

Colon and Rectal Procedures

Colon and Rectal Surgeons treat the patient through procedures performed by various techniques:

• Open surgery

• Laparoscopic surgery

• Hand-Assisted

• Single Port

• Robotic procedure

• Transanal Endoscopic Microsurgery

Open Procedures

• Resections

• Enterectomy (44120 – 44128)

• Colectomy (44140 – 44160)

• Proctectomy (45110 – 45123)

• Repairs (44602- 44680)

• Rectal Repairs (45500- 45825)

• Ileostomy / Colostomy (44310 – 44346)

Surgical Approaches for Open

Procedures1. Kocher’s Incision

2. Midline

3. Gridion Muscle Splitting

4. Battle Incision

5. Lanz Incision

6. Paramedian

7. Transverse

8. Rutherford Morrison

9. Pfannenstiel

Surgical Approaches

The most common surgical approaches for open

abdominal colorectal surgery is:

• Midline

• Transverse

• Pfannenstiel – sometimes referred to as low

transverse incision

Surgical Approaches

• Hand Assisted Laparoscopic – A small incision,

2-3 inches, is used for the hand, and instruments

are use to perform the surgery

• Single Port Site – All instruments are placed

through a small incision usually 2 inches in length

Robotic Surgery

Robotic surgery, or Robotic-assisted surgery is the minimally invasive tool that provides a three dimensional image, uses wristed instruments, and has a computer interface.

• Robotic-assisted colorectal procedures:

• Colon Resection Surgery

• Rectal Resection Surgery

• Rectopexy

Robotic Surgery

S2900 - Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)

• Most payers do not allow additional reimbursement for Robotic-assisted surgery

• Some payers will reject and deny claim using S2900

• Use of modifier 22 is not appropriate

Transanal Endoscopic Microsurgery

TEM or TEMS Procedure

Report using 0184T

TEM is a minimally invasive procedure performed through the rectum with specially designed microsurgical instruments which can remove lesions high inside the rectum. These were previously accessible only with major abdominal surgery.

Transanal Endoscopic Microsurgery

Example:

Following administration of general anesthesia, the

patient is placed in a lithotomy position. Dilation of

the rectum is achieved and maintained with

constant-flow carbon dioxide insufflation. The

proctoscope is inserted and a full-thickness

excision of the tumor is achieved.

TEMS Continued

???????????

45171- Excision of rectal tumor, transanal

approach; not including muscularis propria (ie,

partial thickness), or

45172 – when muscularis propria is excised

**This coding is not accurate and can result in a

post pay recoupment**

Transanal Procedure

Transanal Transabdominal Radical Proctosigmoidectomy with coloanal anastomosis,

TATA Procedure

What is it:

• Endoscopic surgical procedure for the removal of rectal tumors.

Similar to the TEMS procedure, however TATA allows for advanced

visibility, and allows the surgeon to know preoperatively whether the

sphincter can be preserved.

• Abdominal portion is usually laparoscopic

• Follows Chemoradiation

There is no CPT Code

for the procedure

TATA procedure

The abdominal approach begins by using the Da Vinci Si robot. Trocars are placed. After completion of pneumoperitoneum. The patient is placed in the Trendelenburg position. Medial to lateral approach is performed for left colon dissection. The procedure begins with retroperitoneal dissection using the inferior mesenteric vein with a tent to reach the parietocolic gutter. Ligation of the vein and inferior mesenteric artery at its origin. Then is made the release of the colon of the parietocolic gutter and the complete take down of the splenic flexure. It is certified that the colon is with good mobility for a low colorectal anastomosis and then is performed the pelvic approach with robotic mesorectal excision. Transanal approach begins with the use of Transanal Endoscopic Operation. Anal digital expansion is performed for TEO system introduction, pneumoreto is held. Exposition of the dentate line and tumor identification.

TATA procedureDistal margin of resection is defined, making purse string suture to close the rectal stump using 3.0 Vicryl®. After a circumferential demarcation of the rectum with the use of monopolar electrocautery, dissection proceeds to the avascular posterior portion to the pre-sacral fascia, completing the circumferential dissection by mesorectal approach until the peritoneal reflection and reaching the robotic dissection.

Surgical specimen is removed transanally. After extraction of the specimen and colon section was performed purse string suture and a 33 mm circular stapler head is attached and returned the colon into the abdominal cavity. A robotic pouch suture of the rectal stump was performed to proceed the anastomosis with 33 mm stapler. The TEO was held for revision of the anastomosis.

TATA Procedure

No Code???

Open Procedure:

• 44147 Colectomy, partial; abdominal and transanal approach

• 45112 Proctectomy, combined abdominoperineal, pull-through procedure (e.g., colo-anal anastomosis)

• 45119 Proctectomy, combined abdominoperineal pull-through procedure (e.g., colo-anal anastomosis), with creation of colonic reservoir (e.g., J-pouch), with diverting enterostomy when performed

• 45110 Proctectomy; complete, combined abdominoperineal approach, with colostomy

TATA Procedure

Laparoscopic Procedure:

• 44395 Laparoscopy, surgical; proctectomy, complete,

combined abdominoperineal, with colostomy

• 44397 Laparoscopy, surgical; proctectomy, combined

abdominoperineal pull-through procedure (e.g., colo-anal

anastomosis), with creation of colonic reservoir (e.g., J-

pouch), with diverting enterostomy, when performed

TATA Procedure

• Code for the abdominal portion of the procedure using the

appropriate CPT code for approach and resection

• Code 0184T for the TEMS portion of the procedure.

• Provide documentation for reimbursement.

• A 52 modifier may be necessary for abdominal portion of

procedure.

44160, 44140, or 44120

Deciding which to choose between CPT codes

44160, 44140, and 44120 basically boils down to:

• Anastomosis

• Laterality (Right or Left Colon)

44160, 44140, or 44120

44160 – Colectomy, partial, with removal of terminal ileum

with ileocolostomy

Right Hemicolectomy

Cecetomy

Right Colectomy

44205 – Laparoscopic

Anastomosis is between the terminal ileum and the colon.

44160, 44140, or 44120

44140 - Colectomy, partial; with anastomosis

44204 – Laparoscopic

Anastomosis is between the remaining ends of the colon

44160, 44140, or 44120

44120 – Enterectomy, resection of small intestine; single resection and anastomosis.

44202- Laparoscopic

Anastomosis is performed between the remaining small bowel ends

44160, 44140, or 44120

To avoid confusion when deciding which code to assign,

remember:

The documentation must mention that the terminal ileum or

part of the ileum was removed and that the remain ileum

was anastomosed to the colon to bill 44160. Otherwise, for

a colon resection 44140 will be the most appropriate.

44160, 44140, or 44120Example:

The patient was brought to the OR. After being prepped and draped in a sterile fashion, a midline incision was made. Decision was made to proceed with a right hemicolectomy including the small bowel. The left colon was mobilized. The left ureter was identified. The mid descending colon was transected with a stapler. The rectum was mobilized all the way down below the peritoneal reflection. This was then transected, and that specimen was removed. The right colon was identified and was mobilized. A side-to-side, functional end-to-end anastomosis was performed. The small bowel withright colon was removed. The splenic flexure was then taken down using electrocautery, taking down the splenic flexure completely, mobilizing the colon all the way to the level of the mid transverse colon. A purse string suture was placed on the cut end of the colon, and an end-to-end anastomosis was performed using a 29 mm stapler. Insufflation revealed no evidence of leaking..

44140, 44160, or 44120

Because the report states that “The small bowel with right colon

was removed”, CPT code 44160 would be appropriate for

reporting this portion of the procedure.

Correct coding for total procedure:

44145

44160 – 59

Using Modifier 62When billing APR’s, modifier 62 is acceptable when the

physicians have dictated operative reports indicating their

separate performances in the surgical case.

“If the two surgeons (each a different specialty) are required

to perform a specific procedure, each surgeon bills for the

procedure with a modifier 62.” (CMS, 2019)

Co-surgery can also refers to surgical procedures involving

two surgeons, of the same specialty, performing separate

procedure simultaneously.

Using Modifier 62Be sure:

• When billing the surgical procedure with modifier 62, make sure the

documentation of the medical necessity for two surgeons is there

• There is an Indicator of 1- supporting documentation is required to

establish medical necessity of two surgeons for the procedure

• Or Indicator of 2 - the payment rule for two surgeons apply

• Both surgeons append modifier 62 on their claim

• Procedure code and diagnosis code should be same

• One doesn’t bill 44204, the other 45395

Using Modifier 62

• Insurance carriers want providers to use 80, or 82 modifier

• Lower payment to provider: rather pay 116% of fee schedule

than 125%

• Less documentation required

• Lowers the risk of having to pay interest on delayed

payments

Colonoscopy Coding• In CY 2015, the CPT instruction changed the definition of an incomplete

colonoscopy to a colonoscopy that does not evaluate the entire colon. (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4153CP.pdf)

• The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”

• With that change in CPT Manual language, the CMS values in the Medicare physician fee schedule for the following codes: 44388-53, 45378-53, G0105-53, and G0121-53.

Colonoscopy Coding

When covered colonoscopy is next attempted and completed,

the colonoscopy will be paid according to payment methodology

for procedure for either screening or diagnostic colonoscopies

incomplete bowel prep – vs.- large mass

Colonoscopy Coding

• HCPCS/CPT Coding

• G0104: Flexible sigmoidoscopy

• G0105: Colonoscopy, individual at high risk

• G0106: Barium enema –alternative to G0104

• G0120: Barium enema –alternative to G0105

• G0121: Colonoscopy, individual at low risk

• G0122: Barium enema

(noncovered)

• Use when screening barium

enema is not performed as an

alternative to G0104 or G0105

• G0328: Fecal occult blood test

• 81528: Cologuard™ test

• 82270: Fecal occult blood test, 1–

3 simultaneous determinations

Colonoscopy Coding

• Diagnosis Coding

• Z12.11 – Screening for colon cancer

• Z12.12 -for Cologuard Test

• R19.5 – Other Fecal Abnormalities

Colonoscopy Coding

• 2019 Cut in payment

• Watch for billing of multiple colonoscopy techniques in one

session

• Incomplete scopes

• Diagnostic / Therapeutic or Screening

• Because Cologuard testing is indicated in the screening

guidelines, it is considered the screening.

New For 2019

Replacement of gastrostomy tube – 43760

CMS identified code 43760, Change of gastrostomy tube,

percutaneous, without imaging or endoscopic guidance, as a

procedure that could be more complex and require more work

New for 2019

REPLACEMENT CODES