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Cholecystotomy Procedure
How should you code an open cholecystotomy, with a drain placement and a biopsy of the gallbladder wall is performed. Can the biopsy of the gallbladder be separately reported?
Question:
How should you code an open cholecystotomy, with a drain placement and a biopsy of the gallbladder wall is performed. Can the biopsy of the gallbladder be separately reported?
Answer:
No, the biopsy of the gallbladder wall is not separately reportable this is bundled and inclusive to the cholectstotomy. The correct code to report for this procedure would be CPT 47480,Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure).
*This response is based on the best information available as of 12/14/23.
Appendectomy with Cecum Resection
As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy?
Question:
As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy?
Answer:
No, that resection is considered part of the appendectomy procedure and not separately reported.
*This response is based on the best information available as of 11/30/23.
Procedure
When two surgeons work together as primary surgeons performing distinct part(s) of the procedure, and each surgeon reports his/her distinct operative work, what modifier is appended?
Question:
When two surgeons work together as primary surgeons performing distinct part(s) of the procedure, and each surgeon reports his/her distinct operative work, what modifier is appended?
Answer:
When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should report his/her distinct operative work by adding modifier -62 to the CPT code that supports the documentation. The modifier indicates that two surgeons worked together as primary surgeons and performed separate portions of the procedure. Each surgeon needs to separately document their involvement on the procedure.
*This response is based on the best information available as of 11/16/23.
POEM Procedure Coding Part 2
I know the POEM procedure, is reported with code 43497,Lower esophageal myotomy, transoral (ie,perioral) endoscopic myotomy (POEM).One of our surgeon does the G-POEM procedure. This is a gastric peroral endoscopic myotomy (G-POEM) how is this reported?
Question:
I know the POEM procedure, is reported with code 43497,Lower esophageal myotomy, transoral (ie,perioral) endoscopic myotomy (POEM).One of our surgeon does the G-POEM procedure. This is a gastric peroral endoscopic myotomy (G-POEM) how is this reported?
Answer:
There is no current CPT code for this procedure. Report with an unlisted code, 43999,Unlisted procedure, stomach.
*This response is based on the best information available as of 11/2/23.
POEM Procedure Coding Part 1
How is the POEM procedure reported?
Question:
How is the POEM procedure reported?
Answer:
The POEM procedure, Peroral Endoscopic Myotomy, had a new code in 2022: 43497,Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]). Before January 1, 2022, it was reported using an unlisted code. Although 43497 is an endoscopic procedure, it has a 90-day global period according to CMS.
*This response is based on the best information available as of 10/19/23.
Reporting Rives-Stoppa with Hernia Repair
How is a Rive-Stoppa billed with an incisional hernia repair? I’m being told it is a rectus advancement flap and is coded as 15734.
Question:
How is a Rive-Stoppa billed with an incisional hernia repair? I’m being told it is a rectus advancement flap and is coded as 15734.
Answer:
Rives-Stoppa is an incisional hernia repair procedure in which mesh or other prosthesis is placed between the rectus abdominis muscle and the posterior sheath. Rives-Stoppa is considered mesh placement, and as of 2023, mesh placement is included with all hernia repairs.
It is incorrect to report 15734 for a standard Rives-Stoppa repair. Code 15734 may be reported only when musculofascial flaps are created by myofascial release.
Source: ACS Bulletin April
*This response is based on the best information available as of 10/5/23.