The General Surgery Coding Coach 2004 Archives

Question:

I have a question about reporting an incomplete colonoscopy with the modifier 52. If the scope is inserted proximal to the splenic flexure, is this a colonoscopy? The 45378 states “proximal” to the splenic flexure.

Answer:

The following definitions are from the AMA CPT Assistant, Spring 1994.

"Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. For an incomplete colonoscopy, with full preparation for a colonoscopy, a colonoscopy code with the modifier -52 should be used and documentation provided." Remember, Medicare has very specific rules on reporting incomplete colonoscopies on their beneficiaries due to incomplete preps (45378-53, not modifier 52). The intent of the Modifier 52 on this code is to alert the payor that you attempted the colonoscopy but had to abort because the patient was not completely prepped. Medicare uses the Modifier 53 to distinguish frequency as Medicare has local and national policies addressing the frequency of colonoscopies they will cover.

The AMA went on to address a terminology change in the colonoscopy codes. As you note, 45378 reads Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s)by brushing or washing, with or without colon decompression (separate procedure). Key here is the term proximal. The defintion used to say "beyond" the splenic flexure and was changed to proximal to reflect the true anatomic location, thus if you are proximal to the splenic flexur, you have met the definition per CPT.

Question:

Do I use modifier -66 when our General surgeon is operating on a child during the same session as a plastic surgeon doing a cleft palate repair or a urologist performing a urologic procedure such as a circumcision?

Answer:

No, team surgery (modifier –66) occurs when multiple surgeons are performing multiple parts of the same procedure code. In your scenarios, each surgeon submits his/her own claim identifying only the surgical procedure s/he performed. Indicate in the operative note the presence of the other surgeon and that they will dictate their procedure independently.

Question:

If a surgeon treats a patient with a complication in the office, can I append a modifier -78?

Answer:

Modifier 78 reads, “Return To The Operating Room For A Related Procedure During The Postoperative Period.” Based on the definition, modifier -78 is inappropriate if appended to a procedure performed in the physician’s office.

Question:

Our surgeons want to increase their fees when reporting services using the co-surgery modifier. Is this appropriate? We participate in a lot of plans and Medicare.

Answer:

Well they can do this – but it doesn’t mean extra payment. When Medicare reimburses on co-surgery services, they increase the allowable by 25% and then divide that new allowable in half and reimburse both surgeons 62.5% of the allowable. Since reimbursement is made on the plan allowable, increasing your fee inflates your charges, but does not necessarily increase your reimbursement from the payor.

Question:

Our physician performs the “Stretta” procedure on patients who have reflux. I cannot find a CPT code for this procedure. Is there a CPT code or do we have to use an unlisted procedure code?

Answer:

The Stretta procedure is an endoluminal treatment for Gastroesophageal Reflux Disease (GERD) in which radiofrequency energy is delivered to smooth muscle of the lower esophageal sphincter (LES). You are correct in that there is no CPT code for this procedure. The correct CPT code is 0057T Upper GI, including esophagus, stomach, and either the duodenum or jejeunum as appropriate with delivery of thermal energy to the muscle of the lower esophageal stricture and /or gastric cardia, for treatment of gastroesophageal reflux disease.

Question:

A patient had surgery by a surgeon who is not in our group and the procedure has a 90 day global period. She is now scheduled to have another surgery by a surgeon in our group. Do we have to add a modifier to the surgery our surgeon performs since the patient is still in a global period?

Answer:

Your surgeon would not need to add any modifiers since you state the surgery is totally unrelated and not a repeat of the same procedure. Since the first surgeon was performed by a surgeon who is not in your group, the global period only applies to that group.

Your surgeon reports the surgical CPT codes as though the patient has not had any surgery. The patient will then be in a global period for your practice. If the patient returns to surgery during this global period, your surgeon(s) will need to put the appropriate modifier on any surgeries performed during the global period of the surgery performed by your surgeon.

Question:

Our general surgeon was wondering who the “other appropriate source” is in the CPT consultation definition. CPT states a consult is a physician requested service but then goes on to refer to the “other appropriate source”. The physician is wondering if a request from a social worker, dietitian, physician assistant or nurse practitioner would constitute the other appropriate source?

Answer:

The CPT book does not specifically identify who may be considered the “other appropriate source.” According to the CPT Assistant (August 2001), they identify a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language therapist, psychologist, social worker, lawyer or insurance company as a potential other appropriate source. Interestingly, these professionals typically have UPIN numbers from Medicare.

Medicare is very specific in identifying a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist as an appropriate source.

Question:

The physician reported a laryngoscopy, total parotidectomy, and an alloderm implant to the neck. He used the alloderm to fill the defect after the resection. Can he use the 20926 code with a modifier 52?

Answer:

The physician may not separately report the alloderm implant. The CPT codes for the cartilage grafts, fascia grafts, bone grafts and tendon grafts are appropriate when the physician harvests an “autograft” not for the placement of the grafts. Allografts are not separately reportable unless the physician is treating a burn or operating as an assistant surgeon in the spine, where there are specific codes related to those procedures using allografts.

Question:

I used an intercostals block technique after open abdominal surgery that requires a catheter to be placed at the end of the surgical procedure for injection of local anesthesia. Can I report this in addition to the CPT codes for the surgical procedure? If yes, what is the code?

Answer:

Great question and one we are hearing in increasing frequency. Unfortunately the answer is this procedure is not separately reportable. Pain management, local blocks, insertion of pain pumps by the operating surgeon are considered bundled into the global surgical package according to the AMA, and as such, are not separately reportable. If the Anesthesiologist performs these services, the anesthesiologist may report these services in addition to his/her CPT codes for the anesthesia.

Question:

The physician performed a total colectomy on January 19. On February 2nd, the patient presented to our office with complaints of leg pain, swelling and warmth in his left lower leg. The physician evaluated the patient and suspected a deep venous thrombosis and sent him to the hospital for testing. Can the physician report an E&M service for this visit or is it included in the global surgical package.

Answer:

While the deep venous thrombosis (DVT) is an untoward outcome after surgery, it is not a complication of the surgical procedure performed, the colectomy. The physician may report an established patient visit and must append the modifier 24 (unrelated E&M during the global period). Make sure the appropriate diagnosis is linked to the E&M service (diagnosis related to leg pain, swelling)

Question:

My surgeon was asked by an orthopaedic spine surgeon to do the retroperitoneal access to a paraspinal tumor which the spine surgeon removed. The other surgeon could not get access to the tumor so my surgeon did the approach. Should I report this as co-surgery or should I report 49010 (exploration, retroperitoneal areas with or without biopsy(s).

Answer:

The correct way to report this is as co-surgery. The orthopaedic surgeon and your general surgeon will both report the primary procedure as co-surgery, using the exact same CPT code with a 62 modifier. The approach to the spinal procedure is included in the definitive procedure, thus each surgeon is doing distinct separate procedures. If the tumor expands more than one segment, and the two surgeons continue to function as co-surgeons, they may report the appropriate add-on procedures as co-surgeons also.

For example:

63303-62 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach

63308-62 each additional segment (List separately in addition to codes for single segment.

Question:

Can my physician report a hospital inpatient service code or emergency department code and a critical care code on the same day?

Answer:

Yes, you can report both codes but a modifier will be necessary. For example, patient is seen as an in-patient early in the morning. Later that afternoon, the patient requires critical care. Append modifier –25 to the in-patient care code. Indicate the E&M services as significant, separate services on the same day.

Question:

One of our physicians was called for an inpatient consult on a patient. He did the consult and then signed off the case. Five day later, he was re-consulted again. What CPT code can we report?

Answer:

Based on your question, we assume the patient is not in a global period. Report 9926x (Follow-up Inpatient consultation) when the physician is re-consulted during the same hospital stay