The General Surgery Coding Coach 2005 Archives

Question:

How do I code for gastric bypass surgery?

Answer:

In 2005, new codes were introduced the following CPT codes:

43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass an
Roux-en-Y gastroenterostomy

43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption

43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy to limit absorption.

Question:

Can I report wound debridement separately from the wound repair of a gunshot wound?

Answer:

Debridement is included in the exploration of the wound. If however it requires prolonged cleanings as a result of gross contamination then you will need to document the extent of the cleaning and use a -59 modifier.

Question:

Can I report CPT code 11008, removal of prosthetic mesh for necrotizing soft tissue infection, when removing infected mesh previously placed during a laparoscopic procedure?

Answer:

The removal of mesh would be an integral part of any major procedure performed and would not be separately reportable unless it was the only procedure performed. In the situation where the only procedure performed was the removal of infected mesh, report using the unlisted CPT code 49999. The new code introduced in 2005, 11008 is an add-on code for removal of mesh with necrotizing fasciitis.

Question:

Several days following a bowel resection the patient develops a post operative bleed. Can I report for treatment that results in a return to the operating room?

Answer:

According to Medicare, procedures performed as a result of a complication are not reimbursed UNLESS the patient is taken back to the operating room. The treatment requires a trip back to the OR therefore you will need to append the CPT procedure code with a -78 modifier, return to the operating room for a related procedure during the post-operative period

Question:

The patient develops a seroma following mastectomy. What modifier can the physician use to report follow-up services to treat the seroma during the global period of the masectomy?

Answer:

According to Medicare, procedures performed as a result of a complication are not reimbursed UNLESS the patient is taken back to the operating room. The treatment of a seroma is just like treating an abcess and not separately reported on an outpatient basis.

Question:

The surgeon documented in his notes that he “destructed” 13 benign lesions on the chest. Based on his documentation the most appropriate codes are 17000 and 17003. I know the first lesion is reported using the 17000 code, but I am confused with the definition of the 17003. Do I report 17003 one time or 12 times?

Answer:

17003 reads “Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg, actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; second through 14 lesions, each (List separately in addition to code for first lesion).

The CPT definition tells you the 17003 code is for each lesion, the second through the 14th lesion, and to list separately in addition to code for first lesion.

One way to report these to the payor is as follows:

17000 1 unit linked to the appropriate diagnosis code
17003 12 units linked to appropriate diagnosis code.

If you enter your CPT codes by “line item”, you would list 17000 on the first line and then list 17003, twelve times with a “1” in the unit box. You might need modifier -59 (distinct separate procedure) on the second through thirteenth 17003 so the payor doesn't deny these for "duplicate charges". For example, the coding would look like this: 17000, 17003, 17003-59 and report the latter (17003-59) eleven more times."

Question:

One of the physicians in our group saw a patient in the ER on Sunday night. The next day the patient came to the office and was evaluated by another partner. They are both credentialed as the same specialty, so I think this visit is an established patient visit code, but I want to make sure. Is it a new patient visit or established patient visit when the patient is seen on Monday?

Answer:

Great question and great catch! Since the patient was seen in the ER by one partner (same specialty, same group), the visit on Monday is an established patient visit for the second physician (partner).

Question:

One of our physicians saw a hospital patient for a consultation. He did not perform an exam but spent time talking to the patient and wife. The dictation includes a history and discussion but there is no record of an exam. How can I code the inpatient consult without the exam?

Answer:

You mention that the physician spent time talking to the patient and his wife. Did the physician document the total visit time (unit time) and the percent of the time spent on counseling? If yes, you may choose the correct inpatient consultation code (9925x) based on time. Remember, in the inpatient setting, time is total unit time and not just face to face time. However, the physician must have documented the total time and time spent counseling in the documentation you mentioned.

The second option if the time requirement is not met is to report an unlisted E&M code 99499 and send the claim via paper with the note.

Question:

Our physician removed a malignant skin lesion on the right side of neck and did a biopsy of a new lesion on the other side while she was in the operating room. I am new to coding and not sure how to submit these.

Answer:

You report both CPT codes. You did not indicate the size of the lesion or how it was repaired thus we cannot advise on specific CPT codes. We assume the lesion removal will have the highest value thus append a modifier 59 (distinct procedure) to the biopsy. The use of modifier 59 in this situation will indicate that the biopsy was performed at a different site than the lesion removal.

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 patient came in for a screening colonoscopy, but during the colonoscopy the physician found polyps which she biopsied . Do I report the screening colonoscopy or the colonoscopy with biopsy?

Answer:

If during the course of a screening colonoscopy the physician finds pathology and converts to a therapeutic procedure, the physician reports the appropriate therapeutic procedure code and changes the diagnosis to support the procedure. In this case, the appropriate CPT code may be 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The diagnosis would be related to the findings, i.e. polyps.

Question:

We have a new laparoscopic physician in our group. She is documenting “hand-assisted laparoscopic” procedures. Can you advise us on how to code these cases?

Answer:

You would use the same codes for ‘hand-assisted” laparoscopic procedures. For example if the surgeon is performing a laparoscopic colon resection, part of the bowel is brought out even though the approach is laparoscopic. In hand-assisted surgery, the incision may be a little larger, but the approach is still laparoscopic.

Question:

Our surgeons have started performing the “Stretta Procedure” . They mentioned something about an unlisted code, but I am not sure how to code or compare this to report it as an unlisted procedure.

Answer:

Good News! This procedure was a Category III code in 2004. Beginning

January 2005, the AMA has assigned CPT code 43257

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease Code 43257 is intended to be reported for for the treatment of gastroesophageal reflux disease (GERD).

Question:

Can we charge for photocopying records for attorneys, disability claims, etc? I heard that some of our state agencies have a monetary limit but what about private payers?

Answer:

Check your state laws on guidelines for medical record photocopying. Your state's medical association should have this easily available to you. Typically the regulations apply to all payers, not necessarily state vs. private payers.

Question:

We have a new laparoscopic physician in our group. She is documenting “hand-assisted laparoscopic” procedures. Can you advise us on how to code these cases?

Answer:

You would use the same codes for ‘hand-assisted” laparoscopic procedures. For example if the surgeon is performing a laparoscopic colon resection, part of the bowel is brought out even though the approach is laparoscopic. In hand-assisted surgery, the incision may be a little larger, but the approach is still laparoscopic

Question:

Occasionally we will have a patient who sees two of our physicians on the same day because our physicians are subspecialists in Surgery. For example, the patient is seen by two different doctors for his/her (sinus problem and ear problem) (shoulder problem and spine problem) (brain tumor follow-up and spine problem). We billed for both E&M services but only one physician was paid. What can we do to get payment for the other physician?

Answer:

It is a reimbursement problem when two physicians of the same specialty, in the same group practice, see a patient on the same day. It is not a reimbursement problem with two physicians of different specialties, in the same group practice, see a patient on the same day (e.g., your doctor and the internist).

Generally payers do not recognize physician subspecialties. Therefore, they will reimburse for one E&M service per day per specialty in the same group practice. You can appeal for payment on the denied service by submitting both E&M progress notes to show that two separate services were indeed provided by two different physicians. Explain, in a cover letter, the subspecialty nature of your physicians’ expertise (e.g., fellowship training). Good luck!

Question:

Our patient came in for a screening colonoscopy, but during the colonoscopy the physician found polyps which she biopsied. Do I report the screening colonoscopy or the colonoscopy with biopsy?

Answer:

If during the course of a screening colonoscopy the physician finds pathology and converts to a therapeutic procedure, the physician reports the appropriate therapeutic procedure code and changes the diagnosis to support the procedure. In this case, the appropriate CPT code may be 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The diagnosis would be related to the findings, i.e. polyps.

Question:

Can we charge for insertion of a Jackson-Pratt, or penrose, drain when the physician performs a colon resection? If so, what code would we use?

Answer:

You may not bill for this activity. Placing a drainage device in the operative field is included in the global package for any surgical procedure and not separately billable.

Question:

How do I tell if a CPT code is an add-on code? Should I expect full reimbursement on an add-on code, even if it is the second code?

Answer:

There are two places in the AMA CPT Manual where you can determine if a CPT code is an add-on code.

The first place where you can identify which codes are add-on codes is within the body of each section of the CPT code. An add-on code is identified by a + sign in front of the CPT code.

For example, look up CPT code 44139. You will note the listing as follows:

+ 44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure).

In addition to the + sign in front of the code, there are instructions in parenthesis that instruct the physician to “list separately in addition to the primary procedure”.

The second place is in Appendix D of the 2004 AMA CPT Manual. The appendix contains a list of all add-on codes in the entire manual.

The second part of your question asked about reimbursement on add-on codes when they are a secondary procedure. Because add-on codes cannot stand alone, they will always be the second, third, fourth, etc. code. These codes are not subject to the multiple procedure payment formula even if they are the second or third procedure. We expect 100% reimbursement on these codes.

Question:

In the recent ACS Coding and Reimbursement workshop, you mentioned two references for finding when it may be appropriate to report an Assistant Surgeon. Can you identify those sources again?

Answer:

The first source was the Medicare fee schedule. Go to the Medicare website http://www.cms.hhs.gov/providers/pufdownload/default.asp , scroll down and click on RVU04_A.ZIP. If you scroll to the right, you will see those services where Medicare will allow an Assistant, when documentation of medical necessity is required, and when Medicare will not reimburse because the services are exempt from payment for the assistant.

The second source to see when it may be appropriate to report an Assistant Surgeon is the ACS 2002 Assistant at Surgery Study. You may view or download this study on the ACS website. Visit www.facs.org/ahp/pubs/pubs.html to view or download the file.