General Surgery Coding Alert

Make modifier 22 your friend.

What can you do when your surgeon documents an abdominal or pelvic procedure that requires the cutdown of significant adhesions?

Recognize the condition: Adhesions are bands of fibrous scar tissue that may form in the abdomen or pelvis following surgery or infection. Because adhesions connect organs and tissue that are normally separated, they can lead to a variety of complications, including bowel obstruction and infertility, or they may develop asymptomatically. When a surgeon encounters adhesions during a procedure, they may require extensive additional work.

If you know your coding limitations and options, you can often find a way to capture pay for the extended work the procedure requires. Read on to learn how in three easy steps.

First: Know the Codes

CPT^® provides the following six codes for procedures to free adhesions, some of which you may encounter in your general surgery practice:

• 44005 (Enterolysis (freeing of intestinal adhesion) (separate procedure))
• 44180 (Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure))
• 56441 (Lysis of labial adhesions)
• 58559 (Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method))
• 58660 (Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure))
• 58740 (Lysis of adhesions (salpingolysis, ovariolysis)).

Establishing where the surgeon lysed the adhesions is the first step to determine which code to select:

• If the surgeon performed adhesiolysis of bowel/intestinal adhesions, you would report 44005 or 44180, depending on the approach.
• If the surgeon lysed ovarian or fallopian tube adhesions, you should turn to 58660 or 58740, depending on the surgical approach.

Note that CPT^® Assistant (December 2011) clarified that you can report 58660 only for adhesions on the uterine adnexa, but if found in other sites (such as the cul-de-sac, pelvic walls, omentum), you would need to report the unlisted code (49329, Unlisted laparoscopy procedure, abdomen, peritoneum and omentum) instead. Similar logic would apply to the open code 58740, but in that case the unlisted code would have to be 49999 (Unlisted procedure, abdomen, peritoneum and omentum).

Second: Identify the Restrictions

Knowing the adhesiolysis codes is only half the battle when you encounter an op note that documents your surgeon performing the work.

Important: In most cases, you won’t use adhesiolysis codes if the surgeon also performs a more extensive procedure at the site, according to Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

Rationale: Primary surgical procedure codes include the work of typical adhesiolysis, such as using blunt dissection to cut through soft, filmy adhesions to access the surgical site. That’s why most of the adhesiolysis codes include the phrase “separate procedure,” meaning that you should use the code only when the surgeon performs a stand-alone adhesiolysis at that site.

That’s also why you’ll see Correct Coding Initiative (CCI) edit pairs for most abdominal surgeries with 44005 and 44180, and for most pelvic surgeries with 58660 and 58740. Many of those edit pairs have a modifier indicator of “0,” meaning that you can’t use a modifier to override the bundle.

Exception: When your surgeon performs lysis of adhesions in addition to another procedure, you may report one of the adhesiolysis codes only under one the following two conditions:

• The adhesions are in a different anatomic site from the primary procedure
• The surgeon performs and documents extensive lysis of adhesions.

Caution: If “extensive” seems vague, consider these pointers for op-note language that will tip you off to the possibility of reporting additional adhesiolysis work:

• Documentation of adhesion removal using sharp dissection or laser
• Description of adhesions as dense, very adherent, and/or having a blood supply
• Description of work as “unusually difficult,” or similar language
• Quantification of additional time spent relative to typical time for the primary procedure.

Check CCI: If you believe that the op report documents adhesiolysis at a different anatomical site than the primary procedure, or documents extensive additional work beyond the scope of the primary procedure at the same site, you might be able to garner additional pay for the work.

Your first step should be to check CCI edits for bundling between the appropriate procedure code and the appropriate adhesiolysis code. If no edit pair restricts reporting the two codes together, you may proceed to do so.

If the codes are bundled with a modifier indicator of “0,” however, you’ll need to follow the next step as your final option for reimbursement:

Third: Turn to Modifier 22

If your surgeon documents one of the exception for billing adhesiolysis in addition to a primary procedure, your final option for payment is to use modifier 22 (Increased procedural service).

Remember: To report modifier 22, you should have supporting documentation that details the surgeon’s extensive time and work effort. Modifier 22 will most certainly initiate a request for information from your payer, so make sure the operative report substantiates the claim.

Tip: In addition to reporting the time in the procedure note, you should send a cover letter with the claim that compares the additional time and effort to the average time and effort the procedure usually takes. The details that made the procedure difficult provide a better level of understanding to the insurance reviewer who may not be aware of the typical efforts involved in the procedure.

State your pay: If you’re not adding a dollar amount to a claim using modifier 22, you’re doing yourself a disservice. Not including an estimate of what you expect to be paid for the extra work involved in the procedure means you are leaving the decision up to the payer. Payers will often revert to the standard allowable if you don’t ask for more. Including a dollar amount doesn’t mean the payer will reimburse based on your charge, but stating your expectations gives you the best shot.