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Z90.49
ICD-10-CM
Colon Resection

Understanding Colon Resection (Colectomy) diagnosis codes, medical necessity, and clinical documentation requirements is crucial for accurate healthcare billing and coding. This guide covers Bowel Resection, Colectomy procedures, and relevant Colon Resection ICD-10 and CPT codes for proper medical coding and documentation in clinical settings. Learn about post-operative care, complications, and best practices for documenting Colon Resection surgeries.

Also known as

Colectomy
Bowel Resection

Diagnosis Snapshot

Key Facts
  • Definition : Surgical removal of all or part of the colon.
  • Clinical Signs : Abdominal pain, changes in bowel habits, rectal bleeding, weight loss.
  • Common Settings : Inpatient hospital setting, surgical centers, outpatient clinics for follow-up.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z90.49 Coding
0DB60ZZ-0DBB0ZZ

Excision of large intestine, open

Open surgical removal of part of the colon.

0DT60ZZ-0DTB0ZZ

Excision of large intestine, laparoscopic

Laparoscopic removal of part of the colon.

0DTA0ZZ-0DTB0ZZ

Resection of large intestine, laparo

Laparoscopic resection of part of the colon.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the resection partial or total?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Surgical removal of part or all of the colon.
Removal of a section of the small intestine.
Creation of an artificial opening in the abdominal wall for fecal discharge.

Documentation Best Practices

Documentation Checklist
  • Colon resection: Document preoperative diagnosis.
  • Colectomy: Specify extent (partial, total, etc.).
  • Bowel resection: Detail segment, anastomosis.
  • ICD-10-PCS code for colon resection: Verify.
  • CPT code for colectomy: Document approach.

Coding and Audit Risks

Common Risks
  • Unclear Resection Extent

    Documentation lacks specifics on segment, partial vs. total, impacting code selection (e.g., 44140 vs. 44160).

  • Diagnosis Specificity

    Unspecified "Colon Resection" needs clarification. Coding requires detail for accurate DRG assignment like diverticulitis or malignancy.

  • Laparoscopic vs. Open

    Missing documentation of approach (laparoscopic vs. open) affects procedure code and reimbursement (e.g. 44204 vs. 44140).

Mitigation Tips

Best Practices
  • Accurate colon resection coding: Use ICD-10-PCS and CPT codes precisely.
  • Clinical documentation: Specify resection location, extent, and technique.
  • Bowel resection compliance: Adhere to surgical guidelines and payer policies.
  • Colectomy CDI: Capture details like anastomosis, lymph nodes examined.
  • Post-op diagnosis coding: Document complications and follow-up care.

Clinical Decision Support

Checklist
  • Confirm diagnosis: Colon cancer, diverticulitis, IBD, or obstruction documented
  • Pre-op imaging (CT colonography or colonoscopy) reviewed and documented
  • Surgical plan (extent of resection, anastomosis) clearly specified
  • Bowel prep (if applicable) administered and charted appropriately
  • Consent for colon resection, risks, and benefits obtained and signed

Reimbursement and Quality Metrics

Impact Summary
  • Colon Resection (Colectomy, Bowel Resection) reimbursement hinges on accurate ICD-10 and CPT coding, impacting case mix index and revenue cycle management.
  • Coding quality directly affects Colon Resection reimbursement. Correct principal diagnosis and procedure codes are crucial for proper payment.
  • Hospital quality reporting for Colon Resection includes surgical site infection rates and readmissions, impacting value-based purchasing programs.
  • Accurate documentation and coding for Colon Resection complications, such as anastomosis leak, influence hospital quality metrics and reimbursement.

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Frequently Asked Questions

Common Questions and Answers

Q: What are the key considerations for determining the optimal surgical approach for colon resection in patients with diverticulitis?

A: Choosing the best surgical approach for colon resection in diverticulitis depends on several factors, including disease severity (Hinchey stage), patient comorbidities, location of the affected colon segment (sigmoid, transverse, etc.), presence of abscess or perforation, and surgeon experience. Laparoscopic resection is often preferred for uncomplicated diverticulitis due to its minimally invasive nature, potentially leading to faster recovery, reduced postoperative pain, and shorter hospital stays. However, in complex cases involving generalized peritonitis or extensive inflammation, an open approach may be necessary to ensure adequate access and control of the surgical field. Furthermore, the decision between segmental resection and subtotal colectomy needs careful consideration based on the extent of the disease and the risk of recurrence. Explore how minimally invasive techniques can be applied in different scenarios by reviewing recent surgical guidelines and clinical trials.

Q: How can postoperative complications like anastomotic leak be effectively minimized after colon resection surgery?

A: Minimizing anastomotic leak after colon resection requires a multifaceted approach encompassing preoperative optimization, meticulous surgical technique, and effective postoperative management. Preoperatively, addressing factors like malnutrition, smoking, and poorly controlled diabetes can improve tissue healing and reduce leak risk. Intraoperatively, ensuring adequate blood supply to the anastomosis, using tension-free suturing techniques, and avoiding excessive bowel manipulation are crucial. Postoperative strategies include bowel rest, appropriate fluid and electrolyte management, and close monitoring for signs of infection or leakage. Consider implementing enhanced recovery after surgery (ERAS) protocols, which incorporate evidence-based practices to optimize patient care and minimize complications. Learn more about specific surgical techniques and postoperative care strategies that can reduce anastomotic leak rates in various colon resection procedures.

Quick Tips

Practical Coding Tips
  • Code specific resection site
  • Document anastomosis if done
  • Check CCI edits for colonoscopy
  • Query physician for unclear documentation
  • Consider laterality (left/right)

Documentation Templates

Patient presents with symptoms suggestive of a condition requiring colon resection (colectomy, bowel resection).  Presenting complaints include [Specific patient complaint e.g., abdominal pain, rectal bleeding, change in bowel habits, weight loss, fatigue] with onset [Duration of symptoms].  Patient history includes [Relevant medical history e.g., inflammatory bowel disease (Crohn's disease, ulcerative colitis), diverticulitis, colon polyps, colon cancer, familial adenomatous polyposis, Lynch syndrome].  Physical examination reveals [Relevant findings e.g., abdominal tenderness, distension, palpable mass].  Diagnostic workup including [Specific tests e.g., colonoscopy, CT scan of the abdomen and pelvis, barium enema, complete blood count (CBC), carcinoembryonic antigen (CEA) levels] demonstrated [Findings e.g., presence of tumor, stricture, inflammation, obstruction].  Given the findings, a diagnosis of [Specific diagnosis leading to colon resection e.g., colon cancer, diverticulitis, Crohn's disease] is made.  After discussing the risks and benefits of surgical intervention, the patient has elected to proceed with colon resection (colectomy, bowel resection).  A surgical consult has been obtained.  Preoperative orders include [Specific orders e.g., NPO after midnight, bowel preparation, IV fluids, prophylactic antibiotics].  Postoperative care plan includes [Specific details e.g., pain management, wound care, monitoring for complications, dietary restrictions].  ICD-10 code[s] [Insert relevant code(s) e.g., K50.XXX, K57.XXX, C18.XXX, K51.XXX] are being considered for this encounter, subject to confirmation based on definitive surgical findings.  CPT codes for the surgical procedure will be determined and documented postoperatively.  This documentation will be updated to reflect the intraoperative findings and postoperative course.