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, because the enterolysis (44005) is considered an integral part of the excision of the ileoanal reservoir with ileostomy (45136) when performed in conjunction with that procedure. According to CPT guidelines, separate procedure codes should not be reported in addition to the code for the total procedure when they are performed as an integral component of the total procedure.

Documentation States a Surgical Case Includes an Excision of an Ileoanal