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General Surgery Coding Alert

Case Study:

Documenting Separate Incisions Can Get Two Procedures Paid

Published on Mon May 01, 2000

Nugget: Coders can find critical information by carefully reading the body of the surgeon's operative report that allows them to get reimbursed for procedures that may not be listed at the beginning.

Although irrigation and drainage (I&D) usually is bundled into the removal of a foreign body, if the two procedures are performed through separate incisions, they may be billed separately as long as both incisions are documented clearly in the operative report.
 
A coder who only reads the top of the following operative report might assume, on seeing the incision and drainage together with the foreign body removal, that only the removal may be billed.

Operative Report

Preoperative Diagnosis: Abscess, medial aspect right lower leg possibly secondary to foreign body from previous gunshot wound. Retained foreign body from previous gunshot wound, right lateral knee.
 
Postoperative Diagnosis: Same.
 
Procedure: Incision and drainage of abscess cavity, medial aspect, right lower leg down through the fascia with debridement of necrotic tissue and packing open of the wound. Removal of retained subcutaneous foreign body, right lateral knee.
 
History: This 40-year-old man sustained a gunshot wound to the right lower leg about 20 years ago. Approximately two years ago, he began to notice a mass on the medial aspect of the leg, and for about the last three months it has been red, inflamed and draining pus intermittently. It has been drained with recurrence of the abscess. He presents now for incision and drainage with debridement and possible removal of foreign body.
 
Procedure: Under satisfactory IV sedation and the patient in the supine position, the right leg was prepped and draped. The tourniquet was inflated to 300 mm/mercury on the thigh. The roof of the abscess cavity was very thinned out and was excised after cultures were taken. The inflammation appeared to go through the fascia, so the fascia was opened. There was a mass of inflammatory tissue on the fascia and this was sharply debrided. The abscess cavity was totally explored and all necrotic tissue removed. Using fluoroscopy, I located the retained foreign body that was on the medial aspect of the left, and it was far posterior and well away from this wound so it was left in place. It was deep within the muscle belly. Using fluoroscopy, we identified the mass laterally as a small transverse incision made overlying it. A lead B-B was removed. The tourniquet was deflated and good hemostasis noted. A couple of bleeding points were controlled with electrocautery. The lateral incision was closed with two interrupted nylon simple sutures. The medial wound was packed open with Iodoform gauze and a gauze dressing applied. An Ace wrap was applied to hold it in place. The patient was then removed from the operating table and taken to the recovery room in stable condition.

Coding the Procedures

There are three payable codes in this operative session, according to the operative report:
 
  • 27603 (incision and drainage, leg or ankle; deep abscess or hematoma)
     
  • 27372 (removal of foreign body, deep, thigh region or knee area)
     
  • 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy])

    • The surgeon clearly indicated he made two separate incisions, says Karen Evans, RN, CPC, a coding and reimbursement specialist in Mount Vernon, Wash. First, "The roof of the abscess cavity was very thinned out and was excised." Later, "using fluoroscopy," a mass was identified laterally and a small transverse incision made overlying it. Had the op note not made it clear there were two incisions, only the removal of the foreign body could have been billed.
     
    Evans also notes the debridement of necrotic tissue cannot be billed separately. "Although debridement is mentioned, it is considered part of the I&D and therefore, shouldn't be billed, Evans says. "In this case, billing for the debridement of the necrotic tissue would be inappropriate. An I&D was performed, and it includes removing all the necrotic tissue."
     
    Finally, Evans notes that although the op report does describe the two incisions, the descriptions of the procedures at the top of the report are unclear. Even though coders should read the op note all the way through as a matter of course, it would have been helpful if the notes at the top of the report were clearer, she says. "This report is unusual because of the way it is typed up. It takes a lot of concentration to study the different areas." She notes, however, that the surgeon's own coders probably are familiar with his style and may not find the report as difficult to follow as an outsider.
     
    The fluoroscopy can be billed because it was used for a diagnostic purpose (i.e., it was essential in locating the foreign body), says Rebecca Kavin, RN, CPC, an independent coding and reimbursement specialist in La Canada, Calif. "If the hospital also is charging for the flouroscopy, the surgeon should bill 76000 with modifier -26 (professional component) attached.

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