A midline laparotomy incision was made, and exploration of a mass in the mid-sigmoid colon (a pre-operative colonoscopic biopsy-confirmed adenocarcinoma) and surrounding tissues was performed. The sigmoid colon and distal descending colon were mobi-lized after incising the line of Toldt. The proximal site of resection was determined to be at the descending sigmoid junction. The distal site of resection was determined to be at the rectosigmoid junction. These sites were transected using a stapler. The mesentery was taken down at its base using a vessel-sealing device to allow adequate lymph node retrieval for staging, thereby completing a central mesenteric lymph-node dissection that was more extensive than a standard mesenteric lymph-node dissection for benign disease. Colon continuity was restored using a stapler. What is the appropriate CPT code(s) to report for this procedure? ...
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Article Overview
This Find-A-Code article reviews surgical coding for an open colon resection performed through a midline laparotomy for a sigmoid colon mass. It explains the procedure at a high level, identifies the relevant CPT code family, and addresses whether separate reporting of a regional lymphadenectomy add-on code is supported by the documented work. The content is intended for coders, billers, and revenue cycle staff working with colorectal surgery documentation and CPT assignment.
Why This Topic Matters
Accurate CPT selection for colorectal surgery affects claim integrity, compliance, and appropriate reporting of the operative work documented in the record.
What You Will Learn
- How an open colectomy with reconstruction is identified in CPT coding guidance
- How the article frames the relationship between the primary colorectal resection and a separate lymph node dissection code
- What aspects of the operative note are relevant to CPT code selection at a broad level
- How surgical documentation for colon mass resection is interpreted for coding purposes
Who Should Read This
- Medical coders
- Certified professional coders
- Hospital outpatient coders
- Physician billing staff
- Revenue cycle professionals
- Surgical documentation specialists
Codes Discussed
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