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Read colostomy, ileostomy documentation to identify separately reportable procedures

JustCoding News: Inpatient, February 3, 2010

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by Robert S. Gold, MD

Coding for closure or takedown of colostomy or ileostomy requires close examination.

Coders are somewhat adept at identifying codes V55.2 (attention to ileostomy) and V55.3 (attention to colostomy). This is a great start, but they must also capture the operation. For example, they must report ileostomy closure with 46.51 and colostomy closure with 46.52. This is where some coders make mistakes.

Bowel ostomies may be temporary or permanent. The permanent ones typically are not closed later. Coders must understand why the temporary diversion occurred. Patients may have an obstruction, a perforation, or both. Regardless of which is present, there’s no time to prep the patient. And physicians can’t perform a bowel clean-out before initiating a life-saving operation.

The small or large intestines most likely will include some stool. It will consist of some residual food that the patient recently ingested, but most of it will be bacteria.

Performing a prepared bowel resection is risky even when a patient has undergone mechanical and antibacterial preparation of the intestine to make it as clean as possible. With an obstruction or perforation, there is no opportunity to prep the patient. Risks are present even when physicians are able to prepare a bowel.

For example, there is a risk for anastomotic leak and wound infection when a physician preps a patient for a primary anastomosis after resection of a segment of intestine. With an unprepared bowel, it’s often too dangerous to consider a primary anastomosis, and a physician typically performs a diverting ostomy instead. This allows healing and permits an elective bowel prep to precede planned restoration of continuity of the intestinal tract.

Physicians can create different types of stomas during the first operation. During a loop colostomy, the physician brings the large intestine upstream of the obstruction or perforation and through the abdominal wall—typically the transverse colon. The physician usually places the loop of the colon on top of the skin through a hole punched in the full thickness of the abdominal wall. The physician then places a glass rod at a 90º angle to the length of intestine so the bowel won’t slip back into the abdomen.

Next, the surgeon transversely opens the intestine with an electrocautery and places a colostomy bag over the entire site. This bowel-opening procedure typically is performed in the recovery room or at the patient’s bedside several hours after the loop colostomy.

Closing a loop colostomy involves opening the original incision. The opening in the transverse colon may be sutured shut and returned into the abdomen or may be resected. The bowel is returned to the abdominal cavity.

Physicians sometimes perform a resection of a portion of the intestine. This may occur when patients have cancer or a perforation with abscess. Physicians may perform a proximal colostomy with a distal mucus fistula.

During a proximal colostomy, the physician takes the portion of the intestine that was in front of the bad part and places it on the abdominal wall, typically through a stab wound on one side of the midline incision. The physician then brings the other open end beyond where the bad part was removed and places it on the abdominal wall, often through the lower end of the midline incision.

Closing this type of colostomy requires that the surgeon resect the pieces of the intestine that went through the abdominal wall onto the skin. Physicians usually anastomose fresh-cut ends with sutures or some type of stapling technique (e.g., end-to-end, or side-to-side, functional end-to-end). These steps are all integral to colostomy closure. Code colostomy closure only.

Documentation may reference a proximal colostomy with distal “Hartman’s pouch.” The colon (or small intestine) upstream from the damaged area is brought onto the skin surface through a stab wound to one side of the midline incision as an ostomy. The end downstream—the distal end—is stapled shut and dropped back into the abdominal cavity. Physicians perform this procedure when the diseased bowel includes the sigmoid colon, and the rectum is all that remains downstream. The physician closes the rectum and drops it back in because it can’t reach the abdominal wall.

To close this colostomy, the physician clears the proximal (upstream) end of bowel (either colon or ileum) away from the skin. The physician dissects the piece of intestine that went through the body wall from the muscle and fascia and resects that piece of the intestine.

The physician inserts an end-to-end anastomosis (EEA) stapling device into the rectum and advances it to the previous stapled closure of rectum in the belly. The physician places purse-string sutures, removes the previous staple line, and advances the device into the proximal segment. The surgeon tightens the EEA device, fires the staples, and removes the device through the anus.

Surgeons often discuss observation of two intact “doughnuts.” Pathologic exam will confirm that the pieces of intestine were, indeed, intact. Coders should not report the resection of the part of the bowel that comprised the exteriorized colostomy or the doughnuts. Both are integral to the colostomy closure.

Identify reimbursement implications
Assigned codes affect reimbursement, so getting them right is important. For example, principal diagnosis code V55.3 and ICD-9 procedure code 46.52 map to MS-DRG 346 with a relative weight of 1.1881 in 2009. However, adding a resection of a portion of the colon (ICD-9 procedure code 45.79) results in MS-DRG 331, which has a relative weight of 1.6224 in 2009. That’s 33% more dollars.

But don’t report conditions or procedures when doing so is inappropriate. Pieces of the intestine removed with colostomy closure or ileostomy closure are part of the operation and coders should not report either separately.

Know the exception
Only one exception exists—when the physician performs these procedures of true bowel resection separately. Occasionally, the physician performs a diverting colostomy as a life-saving operation, and then later, the patient returns to the operating room (OR) for resection of the offending segment of bowel, and the physician also closes the colostomy. In this situation, code the resection and colostomy closure separately.

Another example occurs when a patient returns to the OR for a colostomy closure and the physician finds additional pathology. In addition to closing the colostomy, the physician may resect a portion of bowel with more diverticula, another mass, or something specifically identified and discussed in the operative report. Report each of these procedures separately.

Read operative reports carefully
Coders must read operative reports. Determine what the physician found and which procedures he or she performed. If documentation indicates the physician simply removed the small segment of bowel that had been exteriorized or examined the doughnuts associated with an end-to-end stapled anastomosis, don’t code it. When the physician actually performs a bowel resection, code it.

See Coding Clinic, second quarter 1991, third quarter 1997, and first quarter 2009. They offer similar advice and provide additional guidance.

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement. Reach him by phone at 770/216-9691 or by e-mail at DCBAInc@cs.com.

This article was originally published in the January issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo at leramo@hotmail.com.



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