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

The correct coding is 45136 only. According to CPT guidelines, when a procedure is described as a "separate procedure," it should not be reported in addition to the code for the total procedure or service. In this case, enterolysis (44005) is considered an integral part of the excision of the ileoanal reservoir with ileostomy (45136), and therefore, should not be reported separately.

Documentation States a Surgical Case Includes an Excision of an Ileoanal