Ostomy Takedown (Ileostomy / Colostomy Reversal)
4462544620wRVU: 14.07 — Closure of enterostomy, small or large intestine, without resection or anastomosis (14.07 wRVU, 90-day global) — use only when no bowel resection and no formal anastomosis are performed (e.g., mucous fistula closure, simple skin-level closure). NOT the correct code for loop ileostomy takedown with stapled side-to-side anastomosis.44626wRVU: 27.2 — Closure of enterostomy with resection and colorectal or coloanal anastomosis (27.20 wRVU, 90-day global) — for Hartmann's reversal with rectal stump reanastomosis
[Loop ileostomy / end ileostomy / loop colostomy / end colostomy], status post [Hartmann's procedure / low anterior resection / small bowel resection / damage control laparotomy] on [date]
Same
[Ileostomy / colostomy] takedown with [primary anastomosis / resection and anastomosis]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] who previously underwent [index procedure] on [date] and had a [loop ileostomy / Hartmann's end colostomy] created at that time. [X] weeks/months have elapsed since creation. The patient has recovered adequately and [distal bowel continuity / anastomotic healing] has been confirmed by [contrast enema / flexible sigmoidoscopy / CT scan] prior to reversal. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.
The [ileostomy / colostomy] was [loop / end] configuration at the [right lower quadrant / left lower quadrant / midline]. The bowel was [viable / healthy] without evidence of [ischemia / stricture / fistula]. [The distal limb was confirmed patent on intraoperative evaluation.] Adhesions were [minimal / moderate / dense], requiring [minimal / significant] lysis. The anastomosis was [hand-sewn / stapled] with [no / minimal] tension.
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics. The abdomen was prepped and draped in sterile fashion.
A circumferential peristomal incision was made around the base of the [ileostomy / colostomy] using electrocautery, staying close to the mucocutaneous junction. The bowel was mobilized from the abdominal wall fascia using sharp and electrocautery dissection, taking care to avoid enterotomy. The bowel was freed to an adequate length to allow a tension-free anastomosis.
[For loop ostomy:] The afferent and efferent limbs were mobilized and the distal limb was confirmed patent by gentle digital probing [or passage of a red rubber catheter]. The bowel was transected at the skin level and the ostomy site was closed primarily [or the bowel was resected back to healthy margins].
[For end ostomy / Hartmann's:] The abdomen was entered through a [midline / Pfannenstiel / periostomy] incision. Adhesions were lysed sharply and with electrocautery. The rectal stump was identified [by digital rectal exam / sigmoidoscopy / transillumination with a proctoscope]. The rectal stump was fully mobilized and the staple line was refreshed.
An [end-to-end / side-to-side] anastomosis was constructed using a [circular stapler, [25 / 28 / 31 / 33] mm / hand-sewn two-layer technique]. The anastomosis was assessed for [integrity / tension / vascularity]. [For colorectal anastomosis: A leak test was performed by submerging the anastomosis in saline and insufflating air transanally; no bubbles were observed.] [A diverting loop ileostomy was / was not] constructed.
The abdominal wall fascia at the ostomy site was closed with [0-PDS] suture. The skin was [closed primarily / left open for delayed closure / closed with a purse-string suture]. The abdominal incision was closed in the standard fashion.
None
[Bowel margin sent to pathology / None]
[X] mL
[None / Jackson-Pratt drain placed in the pelvis]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** ostomy, s/p *** on ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** takedown with ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX s/p *** with *** ostomy presenting for reversal. Distal continuity confirmed by ***. Risks, benefits, and alternatives discussed, consent obtained.
FINDINGS: *** ostomy at ***. Bowel viable. Distal limb patent. Adhesions: ***. Anastomosis: *** without tension.
DESCRIPTION OF PROCEDURE:
Patient supine. General anesthesia. Timeout performed. Prepped and draped in sterile fashion.
Circumferential peristomal incision made. Bowel mobilized from abdominal wall fascia without enterotomy. Distal limb confirmed patent. Bowel transected/resected to healthy margins.
*** anastomosis constructed using ***. [Colorectal: Leak test (transanal insufflation under saline): no bubbles.] Ostomy site fascia closed with 0-PDS. Skin: ***. Abdominal closure: standard.
EBL: ***
SPECIMENS: ***
COMPLICATIONS: None
DRAINS: ***
DISPOSITION: Patient tolerated procedure well, taken to PACU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Hartmann's Reversal
The abdomen was entered through a midline incision. Dense pelvic adhesions were lysed. The rectal stump was identified by transillumination with a rigid proctoscope placed transanally. The stump was mobilized and the staple line refreshed. A [25 / 28 / 31 / 33] mm circular EEA stapler was passed transanally, the spike deployed through the rectal stump, and the anvil (placed in the descending colon) was mated. The anastomosis was fired and two complete donuts were confirmed. The anastomosis was air-tested under saline; watertight. A drain was left in the pelvis given the extent of prior dissection.
Loop Ileostomy Closure
A peristomal incision was made and the loop ileostomy was mobilized from the abdominal wall. The two limbs were freed and healthy margins confirmed. A side-to-side stapled anastomosis was constructed: the two limbs were aligned anti-mesenterically, a GIA stapler was fired, and the common enterotomy was closed with a [linear TA stapler / hand-sewn two-layer technique]. The anastomosis was returned to the abdominal cavity without tension. The fascia was closed with [0-PDS] suture and the skin closed with [subcuticular / purse-string] suture.
Anastomosis Protected with Diverting Ileostomy
Given [low anastomosis / tension / concern for healing], a diverting loop ileostomy was constructed in the right lower quadrant at the time of takedown. The ileostomy was fashioned through a separate trephine incision and matured using Brooke sutures. The patient was counseled that a second takedown procedure will be required after anastomotic healing is confirmed.
Charting Tips
- Document pre-operative confirmation of distal bowel continuity (contrast enema or sigmoidoscopy result). This is essential medicolegal documentation that the patient was appropriately evaluated before reversal and that the distal bowel was patent.
- For colorectal anastomosis (Hartmann's reversal), document the air-insufflation leak test result explicitly — air is insufflated transanally while the anastomosis is submerged in saline. A negative test ('no air bubbles observed') is critical medicolegal documentation. Air insufflation leak testing is not routinely applicable to small-bowel-to-small-bowel anastomoses (loop ileostomy closure) because there is no transanal access to pressurize the bowel lumen.
- For Hartmann's reversal, document the integrity of both donuts from the EEA stapler. Two complete tissue rings confirm full-thickness anastomosis. An incomplete donut mandates further evaluation of the anastomosis.
Billing Tips
- Bill 44625 for closure of enterostomy with resection and anastomosis, other than colorectal (16.85 wRVU, 90-day global). This is the correct primary code for most loop ileostomy reversals — the standard technique involves trimming the stapled ends (a small resection) and constructing a stapled side-to-side anastomosis, which qualifies as resection and anastomosis. 44620 (14.07 wRVU) is correct only when no resection and no formal anastomosis are performed (e.g., mucous fistula closure or simple skin-level apposition). Do not use 44620 for a loop ileostomy takedown with side-to-side anastomosis — this systematically underbills the procedure.
- Bill 44626 (27.20 wRVU, 90-day global) for Hartmann's reversal — closure with colorectal or coloanal anastomosis. Document mobilization of the rectal stump, extent of dissection, stapler size, and donut integrity.
- 90-day global period: anastomotic leak evaluation, wound management, and routine follow-up are bundled. If conversion to permanent ostomy is required intraoperatively, document the reason and use the appropriate colostomy creation code.
- Minimum timing before reversal: loop ileostomy reversal is typically performed at 6-12 weeks (3 months optimal for best functional outcomes); Hartmann's reversal at 3-6 months minimum. Document preoperative confirmation of distal continuity and reason for chosen timing interval.
- When lysis of adhesions is required to safely reach the stoma for takedown, CPT 44005 (enterolysis) carries a 0-modifier NCCI edit and cannot be separately billed with any modifier — it is always bundled into the primary abdominal procedure. Modifier -22 (increased procedural service) added to the primary code (44625 or 44626) is the only available mechanism to capture substantially increased complexity from dense adhesions. Document: specific adhesion burden, OR time exceeding typical range, and how the adhesions increased complexity.
General coding reference. Verify with your institution’s billing department before submitting claims.