AMA CPT® Assistant - 2018 Issue 10 (October)

Surgery: Digestive System (Q&A) (October 2018)

October 2018 page 11a Surgery: Digestive System Question: A patient who is status post-sigmoid colectomy with Hartmann pouch and colostomy has developed a stenotic stoma. The patient presents weekly for either digital dilation or dilation with a Hagar dilator in the office. Documentation includes the following: “Performed stoma dilation with an 11/12-Hagar dilator with both ends passing easily after initial pass.” May this be reported separately using an unlisted CPT code, or is it included in an evaluation and management (E/M) service? Answer: The digital dilation or dilation with a Hagar dilator would be inherent to the appropriate...

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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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