⚕️CPT Code 44020 - Incision and opening of small intestine (enterotomy) for removal of foreign body, concretion, or calculus (separate procedure)

Code Description

CPT 44020 represents an Incision and opening of small intestine (enterotomy) for removal of foreign body, concretion, or calculus. This surgical procedure involves making an incision into the small intestine to extract an obstructing object, such as a swallowed foreign body, a bezoar (concretion), or an enterolith (calculus). It is designated as a “separate procedure,” meaning it is typically bundled into more comprehensive procedures if performed during the same session.^{AMA CPT}

Clinical Overview

This procedure is often performed emergently when a foreign body causes obstruction, perforation, or severe symptoms that cannot be resolved endoscopically. Common foreign bodies include ingested objects (coins, batteries, bones) or pharmacobezoars. The surgeon locates the object, incises the bowel wall, removes the object, and closes the enterotomy site.^ACS

Coding Hierarchy (Code Tree)

This code exists within the following hierarchy in the CPT structure:

Section: Surgery
- Subsection: Digestive System
  - Section: Small Intestine (except Duodenum)
    - Subsection: Incision
      - Code: Enterotomy for removal of foreign body, concretion, or calculus (44020)

Official Coding Guidelines & Notes

Includes

This code includes procedures specified as:

Enterotomy for removal of foreign body
Removal of bezoar via enterotomy
Removal of enterolith via incision^{AMA CPT}

Bundling & Separate Procedure Status

Note: “Separate Procedure” designation means this code should not be reported if performed as an integral part of a larger procedure.

Bundled: If performed during a more extensive small intestine procedure (e.g., resection 44120), do not report 44020 separately.^NCCI
Reportable: Report 44020 if it is the only procedure performed or if performed at a separate session/encounter unrelated to other major procedures.^{AMA CPT}

Excludes

Note: Do not use 44020 for these conditions/procedures.

Endoscopic Removal: If the foreign body is removed via endoscopy, use appropriate GI endoscopy codes (e.g., 43235).
Resection: If a segment of the bowel is resected to remove the object, use resection codes (e.g., 44120).
Duodenum: Procedures on the duodenum have specific codes (e.g., 43650).^{AMA CPT}

Coding Tips

Documentation: Ensure the operative report clearly documents the incision into the small intestine and the specific object removed.
Location: Verify the location is the small intestine (jejunum/ileum), not the stomach or colon.
Method: Confirm the method was open or laparoscopic incision, not endoscopic.
Diagnosis Link: Link to the appropriate diagnosis code indicating the foreign body or obstruction.^{Coding Clinic}

Reimbursement & Risk Adjustment

HCC (Hierarchical Condition Category)

Status: N/A
Reason: HCC models apply to ICD-10-CM diagnosis codes, not CPT procedure codes. However, the diagnosis driving this procedure (e.g., T18.1) may be HCC eligible.^{CMS Risk Adjustment}

wRVU (Work Relative Value Unit)

Value: Yes (Variable)
Reason: 44020 is assigned a wRVU under the Medicare Physician Fee Schedule (MPFS). The exact value varies annually and by facility vs. non-facility setting.^{CMS MPFS}
Impact: Determines physician reimbursement relative to other services.

Assistant Surgeon Payable

Status: Yes
Reason: This code typically allows for an assistant surgeon (modifiers -80, -81, -82) if medically necessary and permitted by payer policy.^{CMS MPFS}

Applicability: No (Inpatient)
Reason: Inpatient hospital reimbursement uses ICD-10-PCS for procedure coding, not CPT. CPT is used for outpatient/physician billing.
APC: For outpatient hospital reimbursement, this code maps to an Ambulatory Payment Classification (APC) under OPPS.^{CMS OPPS}

Coding Examples

Example 1: Foreign Body Removal

Scenario: A patient swallows a chicken bone which becomes lodged in the ileum. Endoscopy fails. Surgeon performs an open enterotomy to remove the bone.

Procedure: 44020 (Incision and opening of small intestine for removal of foreign body)
Diagnosis: T18.1XXA (Foreign body in small intestine, initial encounter)
Diagnosis: K56.0 (Paralytic ileus) - if applicable
Note: Ensure endoscopic attempt is documented if relevant to medical necessity.^{Coding Clinic}

Example 2: Bezoar Removal

Scenario: Patient with prior gastric surgery presents with small bowel obstruction due to a phytobezoar. Surgeon performs enterotomy to extract the concretion.

Procedure: 44020 (Incision and opening of small intestine for removal of concretion)
Diagnosis: K56.2 (Volvulus) - if applicable or K56.50 (Intestinal obstruction, unspecified)
Diagnosis: T18.1XXA (Foreign body in small intestine)
Note: Bezoars are coded as foreign bodies in this context.^{AMA CPT}

Example 3: Separate Procedure Guideline

Scenario: Patient undergoes small bowel resection 44120 for obstruction. During the procedure, the surgeon also removes a foreign body from a different segment via enterotomy.

Procedure: 44120 (Enterectomy, resection of small intestine)
Procedure: 44020 - Do Not Report
Note: 44020 is bundled into the resection as it is a “separate procedure.” ^NCCI

Common modifiers applicable to 44020:

-22: Increased Procedural Services (if work required is substantially greater than typical).
-51: Multiple Procedures (if other distinct procedures are performed).
-59: Distinct Procedural Service (if performed at a different site or session to bypass NCCI edits).
-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.
-79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period.
-80: Assistant Surgeon.
-81: Minimum Assistant Surgeon.
-82: Assistant Surgeon (when qualified resident surgeon not available).^{AMA CPT}

Sources

^{AMA CPT} American Medical Association, CPT Professional Edition. ^ACS American College of Surgeons, Resources for Surgical Practice. ^NCCI CMS National Correct Coding Initiative Policy Manual. ^{Coding Clinic} AHA Coding Clinic for CPT. ^{CMS Risk Adjustment} CMS Medicare Advantage Risk Adjustment Data Processing System. ^{CMS MPFS} CMS Medicare Physician Fee Schedule. ^{CMS OPPS} CMS Outpatient Prospective Payment System.

Explorer

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