AHA Coding Clinic® for ICD-9 - 2010 Issue 3; Ask the Editor

Low Anterior Resection versus Sigmoid Resection

The title of the operative report listed “low anterior resection of the colon.” The surgeon indicates that the colon was pulled down, and there was more than adequate length for resection of the entire sigmoid colon along with a little of the left colon and a little bit of the rectum. A purse-string stapler was fired across the end of the descending colon. The specimen was then resected and removed. A 33-mm stapler was obtained, and the anvil was placed in the end of the descending colon and the purse-string suture was tied. The other end of the stapler was then passed into the rectum and the post perforated through about the midpoint of the staple line of the rectum. The two ends were attached, closed and fired. The bowel was clamped, and then some air was insufflated into the rectum, through the anus, with some water in the pelvis. There was no air leak. Irrigation was then performed, and the fascia was then closed. What is the correct code assignment for this surgery? Is the documentation of “a little of the rectum” enough to assign a code for low anterior resection of the rectum? ...

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