Find comprehensive information on ileostomy reversal surgery, including clinical documentation requirements, medical coding guidelines (ICD-10-PCS, CPT), postoperative care, and potential complications. Learn about the ileostomy reversal procedure, recovery timelines, and healthcare provider considerations for optimal patient outcomes. Explore resources for accurate medical coding and documentation related to ileostomy takedown, closure, or restoration of intestinal continuity.
Also known as
Complications of ileostomy
Covers complications specific to ileostomies, potentially including reversal-related issues.
Other postprocedural disorders of digestive system
Encompasses various post-surgical digestive complications, possibly related to ileostomy reversal.
Other specified postprocedural states
A broader category for post-procedure states, applicable if no more specific code exists.
Follow this step-by-step guide to choose the correct ICD-10 code.
Was the ileostomy created for a benign condition?
Yes
Any complications documented?
No
Any complications documented?
When to use each related code
Description |
---|
Ileostomy Reversal |
Intestinal Obstruction |
Short Bowel Syndrome |
Patient presents for ileostomy reversal surgery. The patient's medical history includes a previously created ileostomy, the indication for which was [original indication for ileostomy, e.g., Crohn's disease, ulcerative colitis, colon cancer, trauma]. The original ileostomy surgery date was [date]. The patient reports [mention symptoms related to the ileostomy or lack thereof, e.g., good stoma health, no complications, manageable output]. Physical examination reveals a [describe stoma appearance, e.g., healthy, pink, well-healed, peristomal skin intact] end ileostomy located in the [location, e.g., right lower quadrant]. Preoperative evaluation includes [mention specific tests, e.g., CT abdomen and pelvis, blood work including complete blood count, comprehensive metabolic panel, coagulation studies]. These tests show [results of preoperative tests, e.g., no evidence of intra-abdominal abscess, normal bowel anatomy visualized, labs within normal limits]. The risks and benefits of ileostomy reversal surgery, including potential complications such as anastomotic leak, small bowel obstruction, wound infection, and recurrence of original disease, were discussed with the patient. The patient understands the procedure and provides informed consent. The plan is for elective laparoscopic ileostomy reversal with intra-abdominal anastomosis. Postoperative care will include bowel rest, nasogastric tube decompression, intravenous fluids, and pain management. Patient education regarding diet progression, wound care, and follow-up appointments will be provided. ICD-10 code K91.88 (Other specified disorders of intestine) and CPT code 44625 (Closure of colostomy or ileostomy) are considered appropriate. This documentation will be updated postoperatively to reflect the surgical findings and intraoperative details.