2025 CPT code 45136
(Active) Effective Date: N/A Revision Date: N/A Surgery - Excision Procedures on the Rectum Surgery Feed
Excision of ileoanal reservoir with ileostomy.This procedure involves the removal of an ileoanal reservoir and the creation of an ileostomy.
Modifiers may be applicable to this code to indicate specific circumstances of the procedure (e.g., increased procedural services, multiple procedures). Refer to current CPT modifier guidelines.
Medical necessity must be clearly established for this procedure. This generally involves documenting complications, failure of the ileoanal reservoir, or other conditions making the reservoir unsustainable.
The physician is responsible for prepping and anesthetizing the patient, performing the surgical excision of the ileoanal reservoir, creating the ileostomy, and closing the surgical site.They also ensure proper placement of the ostomy bag.
In simple words: This surgery removes a pouch (ileoanal reservoir) inside the body that was made from the small intestine and creates an opening in the belly (ileostomy) for stool to pass through.A bag is attached to this opening to collect the waste.
The procedure begins with an incision in the abdomen to access the ileoanal reservoir. The reservoir, a pouch created from the small intestine, is then excised. The anus is closed, and the terminal end of the ileum is brought through an opening in the abdomen to create a stoma. A bag is attached to the stoma to collect waste. Finally, the abdominal incision is closed with sutures.
Example 1: A patient experiences complications with their ileoanal reservoir, such as infection or inflammation, requiring its removal and formation of an ileostomy., Failure of the ileoanal reservoir to function properly, leading to incontinence or other bowel control issues, necessitates conversion to an ileostomy., A patient with Crohn's disease or other inflammatory bowel conditions affecting the ileoanal reservoir may require its removal and creation of an ileostomy.
Documentation should include the medical necessity for the procedure, operative details (including the size and location of the stoma), any complications encountered, and post-operative instructions for ostomy care.Previous attempts at medical management should be noted. Pre-operative imaging and diagnostic reports should also be included.
- Payment Status: Active
- Specialties:General Surgery, Colorectal Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital