General Surgery Coding Alert

"Global periods for major procedures apply only to the surgeon who performed the initial surgery, not to other surgeons who may have assisted with the procedure. In the following case study, a general surgeon who assisted with a radical cystectomy and a right nephrectomy nine days earlier has taken over care of the patient, who needs to return to the operating room. Since the assistant surgeon then is the main surgeon, billing for the new procedure(s) will differ from what it would have been had the same surgeon been in charge of both sessions. Our coding experts will discuss which procedure codes and modifiers should be used and the diagnosis codes associated with the procedures.

Note: Before charging for any procedure, office staff need to carefully check both the operative and pathology reports as well as talk with the physician who did the surgery. Coders should never bill for a procedure unless they have read the entire op report.

Operative Report

Preoperative Diagnoses: Perforated hollow viscus. Poor peripheral veins.

Postoperative Diagnoses: Disrupted ileal anastomosis with peritonitis. Poor peripheral veins.

Procedure: Exploratory laparotomy with small bowel resection and functional end-to-end anastomosis.
Estimated blood loss: 400 cc.

History: The 73-year-old man underwent a radical cystectomy and right nephrectomy nine days ago for CA of the bladder. He had a postoperative stroke but had been doing well. Had x-ray done for placement of a Dobhoff tube today, which showed free air into the diaphragm. Examination of the abdomen revealed tenderness and distention, and his white blood count was elevated. He was brought to surgery for exploration. His peripheral veins are pretty well used up, and he requires reliable venous access.

Operative Procedure: Under satisfactory general endotracheal anesthesia and the patient in the trendelenburg position, the chest and neck were prepped and draped. The skin lateral to the junction and clavicle and first rib was incised. A thin-walled needle was passed into the subclavian vein and a guidewire advanced easily. The dilator followed by the quad lumen catheter were passed over the guide wire and sutured. The tip of the catheter was positioned just above the right atrium using fluoroscopy. The catheter was sutured in place and Betadine followed by a gauze dressing applied.

The abdomen was then prepped and draped. The steri-strips had been removed. The previous mid-line incision was opened and the abdomen entered. The abdomen was explored, with a small amount of stool noted in the left lower quadrant. The small bowel was then dissected out with all the adhesions freed up. The bowel was brought up out of the pelvis. The leak was found to be at the end of the previously stapled functional and end anastomosis. There was no evidence of perforated ulcer or perforated diverticulum. Initially, I considered closing the leak, but I decided that a resection with a new anastomosis would be more appropriate. The bowel was a little friable in the area of the leak, and I was concerned that it would not hold sutures well. The small bowel mesentery was clamped, divided and ligated and a #2-0 chromic ligatures starting just above and ending just below the previous anastomosis. The small bowel was then transected between Cocher clamps and the specimen removed. A functional end-to-end anastomosis was carried out using the GIA stapler and the TA stapler.

The border of the bowel was sutured together with #3-0 silk sutures. The two ends of the GIA were then placed and adjacent loops of bowel and closed. A good area of serosa was approximated. The stapler was fired and the instrument removed. The anastomosis was inspected and no bleeding noted. The open end of the bowel was then closed with a TA 90 stapler. The staple lines were held apart, and the stapler placed across the end of the bowel and fired. The excess bowel was excised. There was a good patent palpable anastomosis and good blood supply to both limbs. Gloves were changed. The corner of the anastomosis was reinforced with #3-0 interrupted #3-0 silk sutures and the stapled end-to-end anastomosis was inverted with interrupted #3-0 silk sutures. The mesentery defect was closed with interrupted #2-0 chromic suture. The abdomen was explored and irrigated and no bleeding noted. There was minimal stool soilage and the wound edges were protected during the case. The bowel was replaced in the abdomen. The anastomosis was just above the ileocecal valve. The abdomen was then closed using interrupted OPDS sutures on the fascia and the skin clips on the skin. A dressing was applied and the patient awakened and taken to the recovery room.

Correctly Coding Procedures and Diagnoses

The first thing to note in the op report above is that because the surgeon in this procedure assisted in the surgery nine days earlier (but was not the primary physician during the original session). The second surgery is not classified as a complication, and modifier -78 (return to the operating room for a related procedure during the postoperative period) does not apply. The assistant in the first surgery is not affected by the primary surgeons global period for the first procedure. In addition, if the assistant in the first procedure assumes care of the patient, he or she can bill for postoperative evaluation and management services prior to the return for surgery, whereas the original surgeon would not have been able to because of the global period.

The primary procedure in this situation was to repair the ruptured bowel. According to Karen Evans, RN, CCS-P, a reimbursement specialist in Mount Vernon, WA, and Margie McLean, chief operating officer, Questcare Practice Management Services in Plano, TX, a coding and billing firm for specialty surgeons, the leaky anastomosis would be coded 44120 (enterectomy, resection of small intestine; single resection and anastomosis). The associated ICD-9 code is 997.4 (digestive system complications).

Evans adds that because the patient had poor venous access due to weak veins, a subclavian IV was inserted into the patient, which should be coded 36489* (placement of central venous catheter [subclavian, jugular, or other vein][e.g., for central venous pressure, hyperalimentation, hemodialysis or chemotherapy]; percutaneous, over age 2]), with the related diagnosis code 459.89 (other specified disorders of the circulatory system; collateral circulation [venous], any site; phlebosclerosis; venofibrosis).

When billing private carriers for a 36489*, Evans recommends using a -59 modifier (distinct procedural service). For Medicare carriers -59 should not be added, because the National Correct Coding Initiative specifically excludes the procedure from any global period.

Note: To support any claim for E/M services, documentation is required. Since this operative report does not provide such documentation, there is no way to be certain that significant E/M services were provided to the patient; therefore, no E/M coding recommendations can be offered in this case study. There is a preoperative component built in to any surgical procedure, says Evans, and the physician could have briefly examined the patient after a complaint of pain and noticed that his white count was elevated and that he had positive peritoneal signs. To claim an examination, Evans says, you need to document the components: medical history, examination, and medical decision-making."