General Surgery Coding Alert

When your close reading of the op report uncovers a second laparoscopic surgical procedure, you have a lot to gain. Let our experts help you focus on the ins and outs of multiple scope coding to capture all the pay you deserve.

If your general surgeon performs multiple surgical laparoscopic procedures during the same operative session, you can report each service separately, in many circumstances. Whether the surgeon plans multiple procedures or performs additional lap services based on findings during surgery does not impact your code selection.

Incision not critical: Contrary to some coders' understanding, "you don't have to have a separate incision to warrant coding a separate laparoscopic surgical procedure," notes Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program. "In fact, a surgeon rarely would need to insert a trocar at a different site to accomplish multiple laparoscopic surgeries."

What is critical to supporting a claim for multiple surgical laps is the surgeon's procedure descriptions. "I always check the physician's documentation carefully," says Sundae Yomes, CPC, coder at HCA Physician Services in Las Vegas. Compare the op report to CPT descriptors to determine which procedure -- or procedures -- to code.

Example: For a patient with Crohn's disease (555.9, Regional enteritis, unspecified site), the surgeon uses a laparoscope to perform a partial resection of the colon and anastomosis (44204, Laparoscopy, surgical; colectomy, partial, with anastomosis). During the procedure, the surgeon notes a gallbladder abscess (575.0, Acute cholecystitis) and performs a laparoscopic cholecystectomy (47562).

"You should report both 44204 and 47562," Bucknam says. "Expect the payer to impose a multiple-procedure payment reduction on the second scope."

Here's how the multiple scope payment works: Payers fully reimburse the procedure with the highest relative value units (RVUs). That's 44204 in this example, which pays $1462.51 (based on 2010 physician fee schedule facility fee using conversion factor 36.0846). Additionally, you'll get 50 percent of the payment for the lesser service -- $348.76 (half of $697.52) for 47562 in this example.

Caution: Although you often can report multiple surgical laparoscopies, you never should report a diagnostic scope (49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) in addition to a surgical scope (such as 44187, Laparoscopy, surgical; ileostomy or jejunostomy, non-tube).

"Most surgical laparoscopic procedures aren't bundled with each other," Bucknam notes. That fact underscores an important point -- barring any bundling issues, "you should report every procedure your surgeon performs."

You will find a few surgical scopes subject to Correct Coding Initiative (CCI) edits, however. "Always check CCI edits before you bill multiple scopes," Yomes says.

For instance: CCI bundles lap appendectomy (44970, Laparoscopy, surgical, appendectomy) with many other surgical lap procedures.

CCI lists 44970 as the column 2 (component) code to multiple codes from the surgical laparoscopy CPT sections for esophagus, stomach, bariatric surgery, intestines, rectum, liver, billiary tract, and abdomen.These edits all show a modifier indicator of "1," meaning that you can override the edit pairs when circumstances warrant.

Watch for "0": CCI also bundles 44970 as the column 1 (comprehensive) code for several procedures. You'll find some of these listed with a "0" modifier indicator, meaning that you can never override the edit pair. For instance, CCI bundles 44970 with 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) showing a "0" in the modifier-indicator column

To report multiple procedures or override CCI edits,you need to be familiar with the following two modifiers:

1. 51 -- Multiple procedures

2. 59 -- Distinct procedural service.

Know the difference: Modifier 51 is an informational modifier to alert payers that you've performed multiple procedures ��" it has nothing to do with bundling issues. In other words, the modifier indicates that the multipleprocedure payment reduction should apply.

Although Medicare and other payers once required modifier 51 when you performed multiple procedures, that's not the case anymore. In fact, many Medicare payers will reject a claim with modifier 51, according to Bucknam. Some Medicaid payers still require the modifier, however. Follow payer instruction to decide whether to use this modifier.

When CCI bundles codes, 51 won't override the edit pair -- but 59 will, in some circumstances. If CCI lists the code pair with a "1" modifier indicator and your surgeon performed separate procedures, you should append modifier 59 to the column 2 code.

Meet "separate procedure" criteria: You should use modifier 59 to override CCI edit pairs only in three circumstances:

• When the surgeon performed the second procedure in another location

• When the surgeon performed the second procedure at a different session (another time on the same date)

• When the first procedure led to the decision to perform the second procedure.

"If you're billing for two distinct lap surgical procedures subject to a CCI edit, you'll have to use 59 -- not 51 -- to override the edit pair," Bucknam concludes.