AHA Coding Clinic® for ICD-9 - 2010 Issue 3; Ask the Editor
Low Anterior Resection versus Sigmoid Resection
The title of the operative report listed “low anterior resection of the colon.†The surgeon indicates that the colon was pulled down, and there was more than adequate length for resection of the entire sigmoid colon along with a little of the left colon and a little bit of the rectum. A purse-string stapler was fired across the end of the descending colon. The specimen was then resected and removed. A 33-mm stapler was obtained, and the anvil was placed in the end of the descending colon and the purse-string suture was tied. The other end of the stapler was then passed into the rectum and the post perforated through about the midpoint of the staple line of the rectum. The two ends were attached, closed and fired. The bowel was clamped, and then some air was insufflated into the rectum, through the anus, with some water in the pelvis. There was no air leak. Irrigation was then performed, and the fascia was then closed. What is the correct code assignment for this surgery? Is the documentation of “a little of the rectum†enough to assign a code for low anterior resection of the rectum? ...
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Article Overview
This coding article reviews a colorectal operative report and explains how the documented surgical approach is evaluated for code assignment. It is intended for coders, auditors, and clinical documentation reviewers working with gastrointestinal surgery records. The article focuses on how operative details and anatomy documentation affect procedure classification, with emphasis on colorectal resection terminology and related coding considerations.
Why This Topic Matters
Accurate procedure selection in colorectal surgery depends on understanding operative documentation, anatomy, and the difference between similar resection types. This topic helps reduce coding errors in surgical claims and supports consistent interpretation of colorectal operative reports.
What You Will Learn
- How operative report wording is evaluated in colorectal surgery coding
- How procedure documentation is compared with surgical anatomy and resection extent
- What documentation elements are relevant when distinguishing similar colorectal resections
- How this type of operative note may affect procedure code selection
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle staff
- Clinical documentation specialists
- Surgical abstractors
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