General Surgery Coding Alert

"When a general surgery coder reads the top of a surgeons operative note that lists a left hemicolectomy, along with repairs of umbilical and incisional hernias, insertion of mesh and insertion of right subclavian IV, she knows both hernias normally are bundled into the hemicolectomy. But by reading the entire op note before filling out the HCFA 1500 claim form, she finds that each of the procedures is separately billable.

In the following operative report, the coder finds a carefully documented description of the surgical procedures that allows her to bill for the incisional hernia and the insertion of mesh because the notes clearly document that separate incisions and repairs were performed during the surgery. This highlights the importance both of reading the entire operative note on the part of the coder and clear documentation by the surgeon.

Operative Report

Preoperative Diagnosis: Polyp, descending colon, umbilical hernia and incisional hernia; poor peripheral veins

Postoperative Diagnosis: Polyp at the splenic flexure, umbilical hernia, incisional hernia; poor peripheral veins.

Procedures: Left hemicolectomy, repair of umbilical hernia, repair of incisional hernia with insertion of mesh; incision of right subclavian IV.

Pathology Report: Pathology for the hemicolectomy returned as villous adenoma with atypia.

Estimated Blood Loss: 200 cc.

History: This 83-year-old female presented with an umbilical hernia and incisional hernia from a CABG incision; she also was found to have a rectocele. She subsequently had a colonoscopy that identified a broad-based polyp in the descending colon. She presents now for resection of the colon lesion and repair of the umbilical and incisional hernias.

Operative Procedure: Under satisfactory general endotracheal anesthesia and the patient in the Trendelenburg position, the chest was prepped and draped. The skin lateral to the junction of the clavicle and the first rib on the right side was infiltrated with Xylocaine and a small incision made. A thin wall needle was passed into the subclavian vein and a guidewire advanced. Fluoroscopy showed the wire to be in the chest. The dilator followed by the Arrow triple lumen catheter were threaded over the guidewire and the tip of the catheter positioned at approximately the superior portion of the right atrium. This was then sutured in place at about 14 cm using the attachable hub. Betadine followed by an occlusive dressing was applied.

With the patient in the lithotomy position, the abdomen and perineum were prepped and draped. A midline incision was made and the abdomen entered. Initially, I was trying to keep the colon resection incision separate from the repair of the incisional hernia, but I had to extend the incision up to the very lower aspect of the hernia. There were some adhesions between the colon and the spleen that were taken down with sharp dissection.

I palpated the colon and found the polyp at the lower aspect of the splenic flexure. The colon was retracted to the right as an incision was made along the peritoneal reflection up the spleen. The renal colic ligament and lienocolic ligament were transected with sharp dissection as the colon was mobilized toward the midline. The omentum was divided along the gastrocolic vessels by sequentially clamping, dividing and ligating the omentum with #2-0 chromic ligatures to the midline.

The remaining omentum was then taken off the colon along the avascular plane. The pancreaticocolic ligament was transected and the colon mobilized medially. The left branch of the middle colic artery was identified and it was clamped, divided, and doubly ligated with #2-0 silk ligatures. The mesentery was then incised out to the bowel to the left of the middle colic vessel. The ascending branch of the left colic artery was then identified, clamped, divided and doubly ligated with #2-0 silk ligatures. The inferior mesenteric vein was left in place.

The mesentery was incised along the vein and the specimen completely freed up. The rest of the colon was palpated and no other lesions removed. A functional end-to-end anastomosis was carried out using the linear cutter on the antimesenteric border, followed by the linear stapler across the open end of the bowel with the previous staple lines held apart. The anastomosis was palpated and found to be widely patent. The staple line was inverted with interrupted #4-0 silk seromusculature sutures circumferentially. Gloves were changed. The mesenteric defect was closed with a running #3-0 Vicryl suture. The abdomen was explored and good hemostasis identified throughout. The remaining omentum was pulled down over the bowel.

The abdomen was then closed with interrupted PDS sutures on the fascia up to the umbilicus. At that point, the umbilical hernia sac was dissected away from the overlying umbilicus and circumferentially dissected out. The sac was excised. The fascia was then approximated with interrupted #0 Vicryl sutures up to the upper end of the incision. We stopped just short of the incisional hernia. The skin in the lower portion of the wound was then approximated with interrupted #3-0 nylon sutures around the umbilicus and at the top and end of the incision. The rest of the incision was closed with skin clips to try to isolate the incisional hernia from the colon resection wound and to have the lower part of the incision closed while we repaired the hernia.

Gloves were changed and the area redraped. An incision then was made over the incisional hernia, which was in the epigastrium. The hernia sac was dissected out circumferentially and about 3 cm of normal fascia cleared off around the hernia defect. The hernia sac was inverted with interrupted #0 PDS sutures. A 6 inch by 4 inch piece of mesh was then placed in the incision and sutured to the fascia circumferentially with interrupted #2-0 Prolene sutures. A small portion of each of the corners were excised to make the mesh fit smoothly. The skin of the hernia site was then closed with skin clips. A dressing was applied and the patient awakened and taken to ICU for recovery.

Coding the Procedure

This operative session should be coded out as follows, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding specialist in Lenzburg, Ill.:

44140 (colectomy, partial; with anastomosis)
49560-59 (repair initial incisional or ventral
hernia; reducible; distinct procedural service)
49568 (implantation of mesh or other prosthesis for incisional or ventral hernia repair [list separately in addition to code for the incisional or ventral hernia repair])
44139 (mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy
[list separately in addition to primary procedure])
36489 (placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperallimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2)
76000-26 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034
[e.g., cardiac fluoroscopy]; professional component)

The correct diagnosis codes are:

235.2 (neoplasm of uncertain behavior of stomach, intestines and rectum) for the left colectomy and the take-down of the splenic flexure
553.21 (ventral hernia; incisional) for the incisional hernia and mesh implantation
459.89 (other specified disorders of circulatory system; collateral circulation [venous], any site) for the subclavian IV and the fluoroscopy

The left colectomy is the primary procedure and is coded 44140, Mueller says. Normally, according to the national Correct Coding Initiative (CCI), 44140 includes the repair of both hernias. But if you can document separate sites for the hernias, attaching modifier -59 (distinct procedural services) will override the CCI edit. In this case, the last two paragraphs document detailed repairs of the incisional hernia and specifically mention the separate site and the reason why it was repaired separately.

The surgeons notes also clearly indicate that the splenic flexure was freed (44139) and that fluoroscopy (76000) was used when inserting the subclavian IV. This procedure takes a modifier -26 (professional component) to indicate the equipment used for the fluoroscopy is owned, leased or rented by someone other than the surgeon or his practice (typically, the hospital).

Also, an error at the top of the operative note easily could lead an unwary coder astray. Among the procedures listed is incision of right subclavian IV. In fact, the IV was inserted, as is clearly indicated in the procedure note (a thin wall needle was passed into the subclavian vein and a guidewire advanced). Had the IV been placed by incision, it would have been coded 36491 (placement of central venous catheter [subclavian, jugular or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; cutdown, over age 2). Coders may easily confuse this code with the correct insertion code (36489).

Note: Claims with modifier -59 attached may be denied on first submission and the op note should be included in an appeal to indicate that the incisional hernia was performed separately.

This case study is a good illustration of the value of coding by operative notes, Mueller says, noting that based on her experiences at many surgical practices, thousands of dollars are sitting in the body of the operative reports that are overlooked because CPT codes are being assigned based only on what the surgeon says was performed or by reading only the top of the op report."