Billing an Appendectomy with Another Surgery

Question:

Is an appendectomy separately reported when done with another abdominal procedure?

Answer:

If the appendectomy is performed for a medically indicated purpose, for example the appendix was involved in the disease process, it can be reported with an add-on code, +44955. See the description of this code below. No modifier would be appended to this code and you should expect 100% reimbursement since add-on codes are valued lower since they are always reported with another procedure.

44955: Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure

*This response is based on the best information available as of 01/04/18.

Coding an Omental Flap

Question:

Can add-on code 49905 (omental flap) be  reported for buttressing an incision or anastomosis?  For example after a colectomy?  Or is the intent of the code, reconstruction of a defect only.

49905 Omental flap, intra-abdominal (List separately in addition to code for primary procedure)

Answer:

No, buttressing a formed anastomosis (made by staples or sutures) with extra suture, mesenteric fat, or even fibrin sealant is all considered inherent to the creation of that anastomosis and would not be separately reported.

*This response is based on the best information available as of 11/16/17.

Billing for Pre-Op H&P Visit

Question:

Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer:

No, the H&P in this case is not a billable visit.  This question comes up often and was addressed by AMA CPT Assistant in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional Question:s. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT says once the decision is made to proceed with surgery the subsequent visits related to the procedure (e.g., doing H&P, getting consent form signed, answering Question:s) are included.  However, in some cases a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease and asthma) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery.  This visit can be billed as an E&M visit as the decision for surgery is just now being made.

*This response is based on the best information available as of 04/27/17.

Coding Laparoscopic Resection

Question:

My doctor performed a laparoscopic resection of a pancreatic lesion. Can this be coded with the open code, since there is no laparoscopic code?

Answer:

CPT says that if there is not a code that describes specifically what was performed, you must use an unlisted code.

Since there are no laparoscopic codes for resection of a lesion of the pancreas, you would report 48999, unlisted code, pancreas. For setting a fee, you can compare the work to the most similar open code, 48120-48160. And remember, if a code does not specifically say “laparoscopic” in its description, it is intended as an open code only.

.*This response is based on the best information available as of 02/02/17.

Coding a Colectomy with Diverting Ileostomy

Question:

How is a partial colectomy with diverting ileostomy coded? The partial colectomy codes say “with colostomy”.

Answer:

Thank you for asking. We have recently revised the recommendation for this procedure based on new information. It is appropriate to use codes that say “with colostomy” (for example, 44141, 44146, 44208) when a diverting ileostomy is performed instead of a colostomy. When these codes were originally valued the codes were valued foreither acolostomy or an ileostomy.

*This response is based on the best information available as of 01/19/17.

CPT Coding for Converting to an Open approach

Question:

My doctor started a laparoscopic cholecystectomy that had to be converted to open due to significant adhesions. He documented both approaches and the laparoscopic approach took significant time before he had to convert to open. Can both be billed?

Answer:

Unfortunately, no. Whenever a “closed” procedure (laparoscopic, arthroscopic, endovascular) is converted to an open procedure only the open procedure may be reported. If a significant amount of time was spent attempting the closed procedure, and this is documented, a 22 modifier for increased procedural services may be appended to the open code. Don’t forget to add the appropriate diagnostic code to indicate the conversion. See the appropriate diagnosis codes below.

• Z53.31 Laparoscopic procedure converted to open

• Z53.32 Thoracoscopic procedure converted to open

• Z53.33 Arthroscopic procedure converted to open

• Z53.39 Other specific procedure converted to open

*This response is based on the best information available as of 10/27/16.