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 alone because the enterolysis (44005) is considered an integral part of the excision of the ileoanal reservoir with ileostomy (45136) when performed in the same operative session. According to CPT guidelines, separate procedure codes should not be reported additionally when performed as an integral component of a more comprehensive procedure.

Documentation States a Surgical Case Includes an Excision of an Ileoanal