Gastroenterology Coding Alert

Heads up: You have more options besides 44955.

You may consider appendectomy as a bundled service with other procedures, but you may be wrong. Appendectomy is separately reportable based on the diagnosis and the physician’s decision and you are forfeiting valuable dollars by giving your appendectomy codes a go by. Follow these tips to ring in the deserved payout for appendix removal.

Tip #1: Give a Wide Berth to ‘Healthy’ Appendix Removal 

You can say goodbye to your reimbursement from majority of payers if your physician has removed a healthy appendix separately. Be prepared to toil with the documentation and op notes to establish for the insurer the medical necessity of the appendectomy your gastroenterologist performed during the same session as another procedure.

Bundled appendectomies performed during the more extensive abdominal procedures are commonplace. As the patient’s abdomen is already open, the physician may usually decide to perform an appendectomy as a foresight to eliminate future health risk for the patient. One instance where this may happen is a bariatric surgery (43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Roux-en-Y gastroenterostomy]). Steer very clear of reporting a separate appendectomy if the finding in the op notes indicates a healthy and normal appendix.

Stay on the right side of audit inspections by spotting the two main conditions where you are allowed to bill for separate appendectomy:

• The physician should clearly note a problematic appendix in his documentation.

• No other procedure during the same session should relate directly to the right colon. If your gastroenterologist performs a medically necessary appendectomy in the same session as another procedure unrelated to the right colon, you can report the appendectomy code in addition to the primary procedure performed.

Tip #2: Capture Appendectomy Codes Accurately for Justified Conditions

If the appendectomy is justified and you have missed the bus on reporting the code, the mistake will extract a significant price on your bottom-line. For example, failure to report the appendectomy code 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]) for an allowed situation will set your practice back by $86.88 (2.43 RVUs times the 2015 conversion factor of $35.7547).

Do not forget to add a valid diagnosis code while reporting 44955 to prove medical necessity of the procedure. If you encounter a blank in the diagnostic code column of the op report, you are in deep trouble because that is clear indication that the appendectomy was redundant and not immediately required. Here, you should avoid separately reporting the appendectomy in totality. Even the CPT® descriptor for 44955 states the need for a supported ICD-9 code by including the phrase “indicated purpose.”

Scenario: While performing gallbladder removal for a patient, the physician visualizes acute appendicitis as well and performs an appendectomy. In this case, you should report 44955 as well as the cholecystectomy (for example, 47562, Laparoscopy, surgical; cholecystectomy). Remember to support the procedure with ICD-9 code 540.9 (Acute appendicitis without peritonitis) to support your 44955 claim. After October, you will report one of the ICD-10 codes K35.80 (Unspecified acute appendicitis) or K35.89 (Other acute appendicitis).

Extract relevant info: You can collect the info on applicable signs and symptoms from the pathology report and/or the physician’s documentation to verify your diagnosis code(s). You are safe in reporting the diagnosis as long one or the other source confirms appendicitis, you can still report 44955. There may be cases where the pathology report may have a negative conclusion for a disease diagnosis, but you can proceed with the claim if the physician states a specific reason for the removal.

Tip #3: Hunt Around for Other Appendectomy Codes

You are doing yourselves a disservice if you don’t venture beyond 44955. You can call on the services of three more codes for appendectomy:

• 44950 (Appendectomy). This is the go-to code when the appendectomy is the primary or the only procedure performed during the session. Collect a cool $663.61 (18.56 RVUs times the 2015 conversion factor of 35.7547) for the procedure.

• 44960 (... for ruptured appendix with abscess or generalized peritonitis). Missing out on 44960 will cost you a heavy $903.16 (25.26 RVUs multiplied by 35.7547).

• 44970 (Laparoscopy, surgical, appendectomy). If your physician removes the appendix laparoscopically in a separate session, you are entitled to report a special code 44970. Ring up your register by an additional $620.34 (17.35 RVUs times the 2015 conversion factor of 35.7547) when you encounter this procedure.

Caution: You should report 44950 and 44970 only for non-ruptured appendix. Go for 44960 if your physician reports a ruptured appendix.