2025 CPT code 44211
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Laparoscopic total colectomy with proctectomy, ileoanal anastomosis with ileal reservoir creation (S or J), loop ileostomy, and rectal mucosectomy.
Modifiers may be applicable depending on specific circumstances (e.g., increased procedural services, multiple procedures). Refer to current CPT coding guidelines for proper modifier usage.
Medical necessity must be established based on the patient's specific condition (e.g., cancer, Crohn's disease, FAP) and the severity of symptoms. Documentation should demonstrate that less invasive treatments were considered or tried and failed.
The surgeon prepares the patient, makes small incisions, insufflates the abdomen, inserts the laparoscope and instruments, dissects adhesions, frees the colon, ligates blood vessels, transects the colon and rectum, performs the ileoanal anastomosis and ileal reservoir creation, creates the loop ileostomy, ensures hemostasis, and closes the incisions.
In simple words: The surgeon removes the entire colon and rectum through small incisions using a camera and specialized instruments. The small intestine is then connected to the anus, creating a pouch. A temporary opening is also made in the abdomen to allow for waste elimination while the surgical area heals.
The provider performs a laparoscopic total colectomy, removing the entire colon through the abdomen, along with a proctectomy (removal of the rectum).An ileoanal anastomosis is created, connecting the ileum (small intestine) to the anus, and an ileal reservoir (S or J shaped) is formed. A loop ileostomy is also created, connecting a loop of the ileum to an external stoma. Rectal mucosectomy (removal of the rectal lining) is included when performed.
Example 1: A patient with colorectal cancer requiring complete removal of the colon and rectum., A patient with severe Crohn's disease unresponsive to medical therapy, necessitating total colectomy and proctectomy., A patient with familial adenomatous polyposis (FAP) at high risk for colorectal cancer undergoing prophylactic colectomy and proctectomy.
Operative report detailing the laparoscopic approach, extent of colectomy and proctectomy, type of ileoanal anastomosis and ileal reservoir, creation of loop ileostomy, and whether rectal mucosectomy was performed. Preoperative diagnostic studies (e.g., colonoscopy, imaging) supporting the diagnosis and medical necessity of the procedure.
- Revenue Code: P1G - MAJOR PROCEDURE - OTHER
- Payment Status: Active
- Specialties:General Surgery, Colon and Rectal Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center