© Copyright 2025 American Medical Association. All rights reserved.
An enterotomy is a surgical procedure that involves making an incision in the small intestine, specifically in a segment other than the duodenum. This procedure is typically performed for various reasons, including exploration of the intestinal lumen, obtaining tissue biopsies, or removing foreign bodies. During the operation, the surgeon makes an incision in the abdominal wall to access the small intestine. The targeted segment of the intestine is then carefully extracted from the abdominal cavity and placed on the operating table for further examination. To facilitate the procedure, pressure is applied to the intestinal segment to express its contents, allowing for a clearer view of the internal structures. The intestine is clamped both distal and proximal to the site of the incision to prevent the contents from spilling into the abdominal cavity. Once the segment is secured, an incision is made in the intestinal wall, and the internal lumen is explored. This exploration may involve taking tissue samples for pathological analysis or removing any foreign objects that may be obstructing the intestine. After the necessary interventions are completed, the intestinal incision is meticulously closed, and the clamps are removed. The segment is then returned to the abdominal cavity, and the abdominal incision is closed. In the context of CPT® Code 44021, the enterotomy is specifically performed for decompression purposes. This involves isolating the segment of bowel to be incised, placing a purse-string suture around it, and making a small nick incision through the intestinal wall. A trocar and cannula connected to suction tubing are then inserted through this incision, allowing the surgeon to decompress the distended loops of intestine effectively. After the decompression is completed, the suction tubing is withdrawn, and the purse-string suture is tied around the incision, with an additional purse-string suture placed around the wound to ensure proper closure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 44021 is indicated for specific clinical situations where decompression of the small intestine is necessary. The following conditions may warrant the performance of an enterotomy for decompression:
The procedure for CPT® Code 44021 involves several critical steps to ensure effective decompression of the small intestine. The following outlines the procedural steps:
Following the completion of the enterotomy for decompression, several post-procedure care considerations are essential for patient recovery. The patient will typically be monitored for any signs of complications, such as infection or leakage from the intestinal incision. Pain management will be provided as needed, and the patient may be placed on a specific diet or intravenous fluids until bowel function returns to normal. It is crucial to assess the patient's recovery closely, ensuring that bowel sounds return and that there are no signs of obstruction or other complications. Follow-up care may include additional imaging studies or evaluations to confirm the success of the decompression and the overall health of the intestinal tract.
| Short Descr | DECOMPRESS SMALL BOWEL | Medium Descr | ENTEROTOMY SM INT OTH/THN DUO DCMPRN | Long Descr | Enterotomy, small intestine, other than duodenum; for decompression (eg, Baker tube) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 96 - Other OR lower GI therapeutic procedures |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.