Documentation states a surgical case includes an excision of an ileoanal reservoir via ileostomy with enterolysis. The coder identifies the following CPT codes to report these services:
44005 - Enterolysis (freeing of intestinal adhesion) (separate procedure)
45136 - Excision of ileoanal reservoir with ileostomy
How should the coder accurately report this procedure within CPT guidelines?

Question

Quizplus · Accepted Answer

According to CPT guidelines, when a procedure described as a "separate procedure" is performed with another related procedure, it is not reported separately. In this case, enterolysis (44005) is considered integral to the excision of the ileoanal reservoir with ileostomy (45136) when performed in the same operative session, thus only 45136 should be reported.

Documentation States a Surgical Case Includes an Excision of an Ileoanal