# Single Incision Laproscopic Surgeries



## ghovey (Oct 16, 2009)

Has anyone done a Lap Cholecysectomy by single incision?  Would you code with 47562 or 47563, same as a regular Lap Chole?  I'm not finding anything else other than an unlisted procedure.  Any ideas????.


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## ASC CODER (Oct 19, 2009)

52 modifier with 47562 or 47563 without reading the op note I don't know which one to tell you.  other wise you would have to use the unlisted.


 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). [revised 1/1/2009]


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## mbort (Oct 19, 2009)

as long as the entire procedure is carried out via laproscopy, i do not think it matters how many portals they use they should still get full credit for the procedures as there is no reduction in what was actually done once they are in there.


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## ASC CODER (Oct 19, 2009)

Lay description 

Four small openings will be made in your abdomen. Carbon dioxide will be pumped in to the abdomen to give the surgeon a better view.

The laparoscope will be inserted through one of the openings. It will provide images of the gallbladder and surrounding area. Special instruments will be inserted through the small openings. They will be used to grasp the gallbladder and clip off the main artery and duct. The gallbladder is then removed through one of the small openings. Dye may be injected into the duct to look for stones. The entire abdomen will be carefully examined for any problems. The keyhole incisions will be closed with a few sutures or staples each. They will be covered with bandages.

I am all for max. reibursement however there is extra work with the scrub nurse holding scope and the additional incisions. I still feel that it is unlisted or reduced procedure. However I am still looking for documentation. This procedure came out in May of 2008 and is still new.  Ill let you know if I find any....


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## ASC CODER (Oct 19, 2009)

Found this from 2009 April, Emerging Technologies, Issue Archives

Single-incision surgery has been given a panoply of acronyms and names, including single-incision laparoscopic surgery (SILS), single-port access (SPA) surgery, laparoscopic endoscopic single-site surgery (LESSS), single laparoscopic incision transabdominal (SLIT) surgery, one-port umbilical surgery (OPUS), natural orifice transumbilical surgery (NOTUS), and embryonic natural orifice transumbilical endoscopic surgery (E-NOTES). SILS has been described since the late 1990s, beginning with appendectomy and cholecystectomy.[24,29] Since then, the technique has been applied to multiple surgical procedures, including gastric banding, sleeve gastrectomy, splenectomy, nephrectomy, colectomy, and adrenalectomy.[24,28] Studies have shown that smaller incisions, including smaller port size, decrease morbidity in both appendectomy and cholecystectomy patients. In comparing patients undergoing needlescopic versus conventional laparoscopic appendectomy, the needlescopic group had a shorter hospital stay (1.3 days vs. 3.2 days), reduced narcotic requirements, and faster return to work (8 days vs. 17 days) than controls.[30] In a similar study pertaining to cholecystectomy patients, the group with downsized trocars reported less incisional pain in the first postoperative week.[31] Based on the results of these studies, it seems logical that eliminating multiple incisions/port sites would further decrease associated morbidity. However, no prospective, randomized study demonstrating clear advantage over standard laparoscopy has been reported.

The tenet of single-incision laparoscopic surgery is to reduce the number of incisions to one, typically at the umbilicus, for multiple trocar placements. This can be accomplished in several ways: a single umbilical skin incision with skin flaps to insert ports through multiple fascial punctures as described by Curcillo, or the use of newly developed systems, such as the Uni-X™ Single Port System (Pnavel Systems, Inc., Morganville, New Jersey), Surgiquest AnchorPort®, TriPort™ (Advanced Surgical Concepts, Wicklow, Ireland), or GelPort® (Applied Medical, Rancho Santa Margarita, California) requiring a larger but single fascial incision for passage of multiple instruments. The required proximity of the trocars at a fixed position illustrates one of the disadvantages of these techniques. The freedom of the hands is relatively restricted, which causes clashing of the instruments, and the fixed port at the umbilicus potentially creates a long distance to the surgical site. This is somewhat contradictory to the traditional teaching of triangulation of instrumentation in laparoscopy, creating a steep learning curve. Thus, the lack of triangulation, pneumoperitoneum leaks, and instrument clashing have been described as real disadvantages of this procedure.[22] Furthermore, there is no long-term data that has examined morbidity of single-incision laparoscopic surgery. Multiple, closely placed fascial punctures have the potential for hernia, and wide skin flaps created to accommodate multiple trocars may result in seroma formation. Still many surgical procedures have been performed safely using these techniques, and variations have been described. As new instruments are developed to accommodate the new paradigm of SILS, it is likely that technical difficulties will be minimized.

Since SILS procedures are relatively new and in evolution, many techniques have been described but no widely accepted standard exists. SILS was first adapted to cholecystectomy and once the technique was shown to be safe and effective for basic laparoscopic procedures, it was applied to some of the technically simpler bariatric procedures. Laparoscopic gastric banding was one of the obvious transitional procedures since the significant incision required for the adjustment port provides the needed space to place multiple trocars. However, laparoscopic banding was more technically difficult due to the camera angles required for dissection of the retrogastric tunnel, the need for retraction of an often-fatty liver from a longer distance, and the need for suturing. As surgeons gained more experience, the technique became more sophisticated, and cosmesis was improved by placing the incision in the umbilicus. With this change, the distance from incision to the surgical field increased and the angle of dissection became more technically challenging. Some have modified this technique by adding a small, second incision for retraction or using specialized ports. With attempts to overcome these obstacles, multiple techniques and instruments have been developed. Because the primary benefit of SILS seems to be cosmetic, most agree that the umbilicus is the preferred incision site; however, it is at this point that the techniques diverge.


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## mbort (Oct 19, 2009)

yea I would definitely like to see something from the AMA or Medicare stating that this is what we should be doing.  

The lay description in the CDR is published by Ingenix and is to be used as a guide and not all procedures are actually performed the way they are published.

anything else you can find from AMA or Medicare would be great.  I've also put a request out on a couple of other list serves to see what everyone else is doing and I will post any additional info that I come up with as well.

thanks


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## ASC CODER (Oct 21, 2009)

here is what I got from coding coach med asssests.

In researching your question, about the definition for LAParoscopic surgery, we came across several definitions. The most common definition includes “LAParoscopy is a type of surgical procedure in which a small INCISION is made, usually in the navel area, other small INCISIONs can be made to insert instruments to perform procedures.”  



After reviewing the different types of LAParoscopy procedures, the number of INCISIONs made during a LAParoscopy procedure may depend on the physician and the type of procedure performed.  For example, in a LAParoscopic colectomy (large bowel resection) the surgeon may create 3 to 5 small INCISIONs to pass the surgical instruments through and the surgeon may also create a 2 to 3 inch INCISION if to allow a  hand inside the patient's abdomen if needed.  Whereas, in a  LAParoscopically assisted vaginal hysterectomy the surgeon may only create 2 to 3 small INCISIONs to insert the LAParoscope and other surgical instruments. 



CMS instructs Medicare providers to report the appropriate surgical CPT code based on the CPT code description that  accurately describes procedure being performed. The surgical LAParoscopy CPT code descriptions do not indicate the number of INCISIONs that are made or should be made during a specific LAParoscopic procedure.  Whether there are 2-3 INCISIONs, 3-5 INCISIONs or 1 INCISION it may be appropriate to report SINGLE INCISION LAParoscopic procedures using the appropriate established surgical LAParoscopy CPT codes .



Because the SINGLE INCISION is a relatively new surgical technology you may also want to query your FI/MAC for further information.


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