44120

Enterectomy, resection of small intestine; single resection and anastomosis

Current Procedural Terminology (CPT) code 44120 represents a surgical enterectomy, specifically defined as the open resection of a segment of the small intestine followed by a single anastomosis to restore gastrointestinal continuity. The small intestine, comprising the duodenum, jejunum, and ileum, plays a critical role in nutrient absorption and digestion. However, various pathological conditions such as severe localized Crohn's disease, benign or malignant neoplasms, mesenteric ischemia, strangulated hernias, traumatic injuries, or refractory bowel obstructions can compromise its integrity, necessitating surgical intervention. During this open procedure, the surgeon makes a laparotomy incision, usually an exploratory midline approach, to gain full visualization of the abdominal cavity. The diseased or damaged portion of the small intestine is meticulously identified. The surgeon then isolates the affected segment by mobilizing it from surrounding tissues and carefully ligating the corresponding mesenteric blood vessels to prevent hemorrhage. Clamps are applied proximally and distally to the diseased area, and the segment is surgically excised (resected). Following the removal of the pathological tissue, the surgeon performs an anastomosis, joining the healthy proximal and distal ends of the small intestine. This connection can be achieved using hand-sewn sutures or surgical stapling devices, depending on the clinical scenario, the surgeon's preference, and the caliber of the bowel. It is critical to ensure that the anastomosis is tension-free, well-vascularized, and leak-proof. The mesenteric defect created during the mobilization is then closed to prevent future internal hernias. Finally, the abdominal cavity is irrigated, hemostasis is verified, and the laparotomy incision is closed in layers. This code is specific to an open approach and a single resection with anastomosis. If multiple discontinuous resections are required during the same operative session, the primary procedure is reported with 44120, and each subsequent resection and anastomosis is reported using the add-on code 44121. If the procedure is performed laparoscopically, an alternative code, such as 44202, must be utilized instead.

Clinical Indications

  • Small bowel obstruction secondary to adhesions, strictures, or internal hernias
  • Crohn's disease refractory to medical management or presenting with complications such as strictures, fistulas, or abscesses
  • Benign or malignant neoplasms of the small intestine, including carcinoid tumors, adenocarcinomas, or gastrointestinal stromal tumors (GIST)
  • Mesenteric ischemia resulting in irreversible necrosis or infarction of a segment of the small bowel
  • Severe abdominal trauma leading to perforation, laceration, or devascularization of the small intestine
  • Intussusception or volvulus causing compromised blood flow and tissue viability

Procedure Steps

  1. Patient is placed under general anesthesia in a supine position and the abdomen is prepped and draped in a sterile fashion.
  2. A standard midline laparotomy incision is made to enter the abdominal cavity.
  3. The peritoneal cavity is explored to identify the diseased, injured, or obstructed segment of the small intestine.
  4. The affected segment of the small bowel is mobilized by dissecting it free from any surrounding adhesions or anatomical attachments.
  5. The mesenteric blood supply to the target segment is identified, isolated, ligated, and divided using sutures, clips, or energy devices.
  6. Surgical clamps are placed on the healthy bowel proximal and distal to the diseased segment to prevent spillage of intestinal contents.
  7. The diseased portion of the small intestine is completely transected and removed from the surgical field.
  8. An anastomosis is created between the proximal and distal segments using either a hand-sewn technique with absorbable sutures or a surgical stapler.
  9. The mesenteric defect is carefully closed with sutures to prevent the risk of a subsequent internal hernia.
  10. The anastomotic site is inspected for hemostasis, adequate blood supply, and tension, and a leak test may be performed.
  11. The abdominal cavity is thoroughly irrigated and inspected for any other pathology or bleeding.
  12. The laparotomy incision is closed in anatomical layers (fascia, subcutaneous tissue, and skin), and sterile dressings are applied.

Coding Guidelines

  • CPT code 44120 is used to report an open single resection of the small intestine with an anastomosis.
  • Do not report 44120 if the procedure is performed via a laparoscopic approach; use CPT code 44202 for laparoscopic enterectomy.
  • If multiple resections and anastomoses are performed on the small intestine during the same operative session, report 44120 for the first resection and add-on CPT code 44121 for each additional resection and anastomosis.
  • CPT code 44120 includes the exploratory laparotomy; do not separately report 39000 or 49000.
  • If a stoma (enterostomy) is created instead of an anastomosis, consider reporting CPT code 44125.
  • Do not append modifier 50 (Bilateral procedure) as this code represents an unpaired organ system.
  • Modifier 22 may be appended if the work required to perform the enterectomy is substantially greater than typically required, supported by comprehensive operative documentation.
  • When performed in conjunction with another major procedure, standard National Correct Coding Initiative (NCCI) edits must be checked to determine if a modifier (e.g., 51 or 59) is appropriate.

Associated ICD-10 Codes