General Surgery Coding Alert

Focus on rules for ‘unlisted’ procedures.

Take a peek at the following case to garner tips for coding unlisted procedures, multiple scopes, and more.

The case: The surgeon performs a laparoscopic hernia repair for a patient with a newly-identified bulging inguinal hernia. During the procedure, the surgeon recognizes and removes an enlarged lymph node from the groin region.

Identify Primary Procedure Code

The surgeon’s primary objective for this surgery was to repair an initial inguinal hernia bulging through the posterior wall of the inguinal canal. The op report documents making two small incisions in the abdominal wall, inflating the abdomen, inserting a scope and surgical instruments through the incisions, and pushing the herniated intestine back into place before placing mesh over the defect in the abdominal wall.

Because the surgeon documents a laparoscopic approach, the best code to describe the surgeon’s work is 49650 (Laparoscopy, surgical; repair initial inguinal hernia).

Avoid: Don’t use an open code for inguinal hernia repair, such as 49505 (Repair initial inguinal hernia, age 5 years or older; reducible).

Focus ‘Unlisted’ Procedure Rules

While observing the area with the scope, the surgeon notes and excises a suspicious inguinal lymph node.

Although CPT^® provides a specific code for inguinofemoral lymph node excision, this case does not warrant using the code: 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)). You can see that 38531 describes an open procedure, but the surgeon in this case removes the inguinal lymph node laparoscopically.

Do this: “Report the procedure using an unlisted code such as 38589 (Unlisted laparoscopy procedure, lymphatic system) for the laparoscopic inguinal lymph node excision,” advises Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, national director of marketing and revenue management at FasPsych in Omaha, Nebr.

Key: Never report a code that comes close to the provider’s service but doesn’t quite fit. Instead, CPT^® instructs you to report the service “using the appropriate unlisted procedure or service code.” Your surgeon will need to specifically describe what was done and why so you can convey this information to the payer for coverage of the unlisted procedure.

Expert tip: For an unlisted procedure, “I recommend first sending in the claim electronically without the documentation so that you have proof of timely filing, and then sending the documentation with a statement on the claim saying that this is a documentation copy, not a duplicate copy,” says Barbara Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Pricing: Because unlisted codes don’t come with a set fee schedule amount, you’ll need to suggest a fee to the payer. Start by comparing the unlisted procedure to similar, listed procedures that have an established reimbursement value, then tell the payer how the work in this case is similar to or different from the listed codes.

Understand ‘Multiple Scopes’ Rule for Better Pay

When a surgeon performs multiple laparoscopic procedures during the same operative session, you can separately report each service, in many cases.

Myth: Some coders believe that you must have a separate incision to warrant coding separate laparoscopic procedures, but that’s not true.

Fact: What does matter is detailed documentation of the surgeon’s work. In this case, the surgeon documents the findings that led to the decision to remove the lymph node in addition to the hernia repair.

Multiple scopes: You should expect a multiple-procedure payment reduction on the second scope. The payer will fully reimburse the procedure with the highest relative value units (RVUs), plus 50 percent of the payment for the lesser service.

Check CCI: Most surgical laparoscopic procedures aren’t bundled under the Correct Coding Initiative (CCI), including the two codes in this case. That means there’s no roadblock to reporting the codes together, and you don’t need a modifier such as 59 (Distinct procedural service) to override an edit pair.

Although payers once required modifier 51 (Multiple procedures) as an informational modifier to signal the multiple procedure price reduction, that’s no longer required by most payers.