Gastroenterology Coding Alert

Billing multiple scopes could bring your practice legitimate pay, or it could bring you fraud charges. If your practice is performing diagnostic laparoscopy, your job is to know the difference -- and our job is to show you how.

Follow these three tips to make sure you avoid the pitfalls and capture the opportunities inherent in laparoscopy coding.

When a surgeon performs a diagnostic laparoscopy, the findings sometimes lead the physician to determine the need for an open surgical procedure. In these cases, you can separately report the diagnostic laparoscopy.

Check CCI: If the Correct Coding Initiative (CCI) bundles the diagnostic scope with the code for the open procedure, you'll have to append modifier 59 (Distinct procedural service) to the "component" procedure (which usually has fewer relative value units [RVUs]) to override the edit pair. You can use this modifier only when the procedures involve separate sites or operative sessions.

Additionally, "the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy," according to CMS.

Beware 58: Although the CCI policy manual states that you should use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) in these cases, most Medicare payers will reject the claim with that modifier.

Because 58 describes a procedure in the postoperative period, you should reserve the modifier for a service that happens one day or more after the initial surgery.

Resource: CMS guidelines specifically state that if the surgeon performs an endoscopy for an initial diagnosis on the same day as the open procedure, you may separately report the endoscopy. You can read the guidelines in chapter 6 of the National Correct Coding Initiative Policy Manual at www.cms.hhs.gov/NationalCorrectCodInitEd.

Example: A patient presents with left upper quadrant pain (789.02, Abdominal pain, left upper quadrant). The surgeon schedules a diagnostic laparoscopy (49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washings [separate procedure]).During the diagnostic scope procedure, the surgeon identifies an enteroenteric fistula (569.81, Fistula of intestine, excluding rectum and anus). The surgeon decides to perform an open surgical repair that same day (44625, Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal).

In this case, because the scope determined the need for the repair, you should claim both 44625 and 49320. Capturing the 49320 service means an extra $298.99 for your practice (based on the 2009 Medicare physician fee schedule national facility total RVUs). CCI does not bundle these codes, so you won't need a modifier.

Get real: If the surgeon uses the scope prior to open surgery as a tool to establish anatomic landmarks or to discern the extent of disease, you should not separately report a diagnostic scope, notes M. Tray Dunaway, MD, FACS, CSP, a surgeon, author, speaker, and coding educator with Healthcare Value Inc. in Camden, S.C. The surgeon must have scheduled a scope procedure to determine a diagnosis, and the scope must have led directly to the decision to perform surgery for you to code both procedures.

Surgeons don't frequently perform diagnostic laparoscopies, so coding a diagnostic scope and an open surgery together would be unusual, according to Dunaway.

What if the surgeon begins a laparoscopic surgical procedure, then determines the need to convert to an open procedure?

That's different: Although both situations 1 and 2 involve a scope followed by an open surgery, you bill the situations differently:

• diagnostic laparoscope followed by open surgery -- bill both

• surgical laparoscope converted to open surgery -- don't bill both.

When the surgeon converts an endoscopic procedure into an open procedure, you should report only the successful (open) procedure, according to CMS and CCI guidelines.

Example: Based on a diagnosis of cholecystitis, the surgeon first attempts to laparoscopically remove the gallbladder (47562, Laparoscopy, surgical; cholecystectomy).

Due to complications, he converts to an open cholecystectomy (47600). In this case, you would report only the open procedure.

Opportunity: Because open conversion cases often take much longer than a similar procedure that is open from the start, you might be able to use modifier 22 (Increased procedural services). The surgeon must document the extra work and time for you to be able to use this modifier.

When the surgeon performs a diagnostic laparoscopy followed by a surgical laparoscopy, you may report only the surgical procedure. Even if the diagnostic scope findings prompted the surgical laparoscopy, you can't report both procedures, says Sarah L. Goodman, MBA, CPC-H, CCP, FCS, president of SLG Inc. in Raleigh, N.C. As CPT instructions clearly state, "Surgical laparoscopy always includes diagnostic laparoscopy."

Example: The surgeon performs a diagnostic scope (49320) for a patient with right upper quadrant pain (789.01, Abdominal pain, right upper quadrant) and discovers a gallbladder abscess (575.0, Acute cholecystitis).

The surgeon proceeds to laparoscopically remove the gallbladder (47562).

Because surgical scope always includes the diagnostic scope, you should not bill for 49320. For this case, report only the surgical scope (47562).