General Surgery Coding Alert

Identify standard surgical services to steer through bundle traps.

Not one new CPT® 2012 code that you're likely to use in your general surgery practice escapes the latest edition of Medicare's Correct Coding Initiative (CCI).

CCI released version 18.0, effective Jan. 1, revealing 15,530 new active pairs and 6,197 code pair terminations, according to Frank D. Cohen, MPA, MBB, senior analyst with Frank Cohen Group, LLC.

From new skin to abdominal surgical codes, make sure you comply with the following CCI edits when you bill new CPT® 2012 codes.

Infusions, Imaging, and Anesthesia Included

Medicare specifies that when you bill a surgical code, the procedure includes all intraoperative services that are usual and necessary parts of the surgery. That's why CCI 18.0 contains thousands of new edit pairs with the following CPT® 2012 codes that you might use in your surgical practice this year:

• 15271-+15278 -- Application of skin substitute graft ...
• 15777 -- Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (e.g., breast, trunk) (List separately in addition to code for primary procedure
• 36251-36252 -- Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image post processing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed;...
• 36253-36254 -- Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; ...
• 37191 -- Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
• 37192 -- Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
• 37193 -- Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and  interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
• 49082-49083 -- Abdominal paracentesis (diagnostic or therapeutic); ...
• 49084 -- Peritoneal lavage, including imaging guidance, when performed.

Know the column 2 codes: With the above new surgical codes in column 1, CCI 18.0 creates edit pairs with the following procedures that Medicare considers "column 2" (component) codes:

• Venipuncture, IV, infusion, transfusion, or arterial puncture services represented by codes such as 36000, 36400-36410, 36430-36440 36600, 37202, 96360, and 96372
• Naso- or oro-gastric tube placement (43752)
• Bladder catheter placement (51701-51703)
• Many nerve block codes in the range 62310-64530
• Operating microscope (+69990)
• Many electrocardiogram (ECG) and electroencephalography (EEG) codes such as 93000-93010 and 95812-95822
• Pulmonary services such as 94002, 94200, and 94680
• Moderate sedation codes such as 99148-+99150.
• You should study these bundles carefully, because CCI assigns many of the new edit pairs a "0" modifier indicator, meaning that you cannot override the edit pair under any circumstances.

"This large number of new edit pairs is part of the previous pattern of Medicare bundling ancillary services that are typically part of procedures," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "Coders should watch closely for those types of changes and bill accordingly."

Don't Miss These Imaging Bundles

You'll find some imaging services bundled as column 2 codes with several new surgical codes in CCI 18.0. For instance, new vascular codes 36251-36254 and 37191-37193, as well as new abdominal codes 49082-49084, list the following fluoroscopy services as column 2 codes:

• 76000-76001 -- Fluoroscopy ...
• 77001-77002 -- Fluoroscopic guidance for ... placement.

You'll also find the vascular codes bundled with aortography and venography codes such as 75625 and 75831.

Look for ultrasound pairs: CCI 18.0 also bundles 36251-36254, 37191-37193 and 49082-49084 with ultrasound codes 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) and 76998 (Ultrasonic guidance, intraoperative).

A new CPT® 2012 text note following 76942 restricts the code's use, but not with any of the new vascular codes identified in these CCI edits:

"Do not report 76942 in conjunction with 27096, 37760, 37761, 43232, 43237, 43242, 45341, 45342, 64479-64484, 64490-64495, 76975, 0228T-0231T, 0232T, 0249T."

Terminate Nearly 2000 Skin Substitute Bundles

No matter what type of skin substitute your physician uses -- allograft, acellular dermal allograft, tissue cultured allogeneic dermal substitute skin substitute, tissue cultured allogeneic dermal substitute, xenograft, or acellular xenograft implant -- you'll turn to new codes 15271-+15278 in CPT® 2012.

Old way: Prior to Jan. 1, you would pick your skin substitute code based on what type of product the surgeon used. Now all that's changed, because CPT® 2012 deletes the following six code families:

• 15170-+15176 -- Acellular dermal replacement ...
• 15300-+15321 -- Allograft skin for temporary wound closure ...
• 15330-+15336 -- Acellular dermal allograft ...
• 15340-+15341 -- Tissue cultured allogeneic skin substitute ...
• 15360-+15366 -- Tissue cultured allogeneic dermal substitute ...
• 15400-+15421 -- Xenograft skin [dermal] for temporary wound closure ...
• 15430-+15431 -- Acellular xenograft implant ....

Those deletions are the source of nearly 2000 CCI 18.0 edit pair terminations.

New way: Now you'll pick the skin substitute code based on the wound site and size from the code range 15271-+15278. And you'll need to be aware of new CCI 18.0 edit pairs that bundle many of these new codes with many of the following services in column 2:

• Simple repair codes such as 12001-12021
• Intermediate repair codes such as 12031-12057.
• Complex repair codes such as 13100-13152
• Burn debridement codes such as 16020
• Casts, splints, and strapping codes in the range 29000-29584.