General Surgery Coding Alert

Apply modifier 52 with 43770 for placement of an individual component

After years of reporting an unlisted-procedure code--with all its attending documentation complications--you can now select a dedicated CPT code for laparoscopic banding gastric restrictive surgery. In addition, you-ll have new codes to describe open revisions and removal of the subcutaneous port.

Familiarize Yourself With the New Codes

Instead of unlisted-procedure code 43659 (Unlisted laparoscopy procedure, stomach), you can now report 43770 (Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band [gastric band and subcutaneous port components]) for laparoscopic band procedures

How it works: During the procedure, the surgeon--using laparoscopic techniques--places an adjustable silicone band just below the gastroesophageal junction, says  Giselle G. Hamad, MD, FACS, assistant professor of surgery at the University of Pittsburgh. The band connects to an access port, into which the surgeon may inject (or aspirate) saline to expand (or contract) the band and effectively manipulate stomach size (and thus, control appetite suppression, satiety and weight loss).

Because the surgery requires the physician to place both the adjustable band and subcutaneous port, CPT has included several companion codes for 43770 to describe subsequent revision or removal of the individual components, including:

- 43771---revision of adjustable gastric band component only
- 43772---removal of adjustable gastric band component only
- 43773---removal and replacement of adjustable gastric band component only
- 43774---removal of adjustable gastric band and subcutaneous port components.

You should not report 43772 and 43773 for the same session. Removal and replacement of the gastric band (43773) includes removal as described by 43772.

Don't Confuse Revisions and Adjustments

Although appropriately applying 43771-43774 is mostly self-explanatory, you must be careful to make one distinction: Gastric band adjustments (by saline injection or aspiration) are not the same as revisions as described by 43771, Hamad says.

The surgeon performs -adjustments- routinely  (generally in the office) several times a year to optimize weight loss. You should include such adjustments to the gastric band by saline injection/aspiration (which is a nonsurgical procedure) as a standard postoperative component of 43770 and 43773, according to CPT rules and the AMA's CPT Changes 2006: An Insider's View.

In other words: You cannot report a separate service for band adjustments during the primary procedures- global period.

On the other hand, gastric band revision (43771) involves laparoscopic surgery to manipulate a gastric band placed during a previous procedure. Such revisions are not routine, and a surgeon would only undertake such a procedure to manage a complication, Hamad says.

Modifiers, Unlisted Codes Make Up for Gaps

In two circumstances, you still cannot call on a dedicated CPT code to describe a procedure associated with laparoscopic gastric banding, Hamad says. These include placing either the gastric band or the subcutaneous port components only, or removing and replacing both the gastric band and subcutaneous port components.

When the surgeon places either the gastric band or port components only, you should report 43770, but append modifier 52 (Reduced services) to indicate that the surgeon did not perform the -complete- procedure, according to CPT guidelines.

In the second case (when the surgeon removes and replaces both the gastric band and subcutaneous port components), you must reach for 43659, CPT says.

Open Codes Complement Laparoscopic Procedures

You-ll find one revised and three new codes to describe open gastric bypass procedures in CPT 2006.

The first of these, 43848, has undergone a rewrite this year and describes Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure). As directed by the code descriptor, you should apply 43848 for all open revisions of gastric bypass procedures, except those involving gastric bypass bands.

Parenthetical references direct you to report 43770-43774 (explained above) for laparoscopic revision of gastric bypass bands and 43886-43888 (explained below) for open revisions of gastric bypass bands.

The three all-new codes mirror somewhat their laparoscopic counterparts 43771-43774, as follows:

- 43886--Gastric restrictive procedure, open; revision of subcutaneous port component only
- 43887---removal of subcutaneous port component only
- 43888---removal and replacement of subcutaneous port component only.or aspiration) are not the same as revisions as described by 43771, Hamad says.

Don't Report Lap and Open Codes Together

You should observe correct coding conventions by not reporting both a laparoscopic procedure and the analogous open procedure for the same session, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif. Instead you should report only the open procedure.

For example: You should not report 43888 with 43774, according to CPT, because these codes describe different methods of achieving the same ends (removal and replacement of the subcutaneous port component). If the surgeon attempts the procedure using the laparoscope, but must convert to an open procedure, report 43888 only.

Such conversions are rare, however, and usually occur when there is little abdominal space, difficult exposure, bleeding, or other situations that make the laparoscopic approach difficult or unsafe, Hamad says.

Tip: When reporting an open procedure that the surgeon has converted from a laparoscopic procedure, be sure to add V64.41 (Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis.

In addition, just as you should not report 43772 (lap removal of port) and 43773 (lap removal and replacement of port) for the same session, you should not report 43887 (open removal of port) and 43888 (open removal and replacement of port) together. Code 43888 includes the work involved in 43887.