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General Surgery Coding Alert

CCI 7.2 Adds Hundreds of Surgery Edits

Published on Wed Aug 01, 2001

Version 7.2 of the national Correct Coding Initiative (CCI), effective July 1, includes many edits of interest to general surgeons. Of particular note are changes for the following five procedures, which are now bundled with hundreds of other codes:

  • 49000 -- exploratory laparotomy, exploratory celiotomy with or without biopsy(s)(separate procedure)
  • 49002 -- reopening of recent laparotomy
     
  • 44200 -- laparoscopy, surgical; enterolysis (freeing of intestinal adhesion)(separate procedure)
     
  • G0168 -- wound closure utilizing tissue adhesive(s) only
     
  • 97601 -- removal of devitalized tissue from wound; selective debridement, without  anesthesia (e.g., high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.
    •  
    These codes, otherwise unrelated, all describe a service usually considered incidental when performed with another, more extensive procedure. By making hundreds of code combinations involving these procedures explicitly nonpayable, CCI is reinforcing widely accepted (but in some cases, poorly understood) coding conventions.

    44200: Separate Procedures Are Usually Bundled
     
    Any CPT-designated "separate procedure" can normally be billed when it is the only procedure performed. For instance, 44200 is included in any more extensive procedure -- laparoscopic or open -- during the same operative session.
     
    Note: This rule does not apply to entirely unrelated procedures (for example, procedures in a different body area). In such cases, append 44200, for instance, with modifier -59 (distinct procedural service) to indicate the procedures are separate and should not be bundled.
     
    Version 7.2 bundles 44200 to more than 300 codes, of which most are surgery codes in the digestive or genitourinary sections (40000 and 50000 series, respectively) of CPT. Although separate-procedure status is one of the criteria by which CCI bundles codes, not all CPT-designated separate procedures are bundled. As with 44200 in this case, however, individual edits involving the CPT-defined separate procedure are often added to subsequent versions of the CCI.
     
    Most of the 300+ codes that now bundle 44200 describe open procedures, notes Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. "Laparoscopic lysis of adhesions, like open lysis of adhesions [44005], was already bundled with lap choles [47562] and most other laparoscopic abdominal procedures -- as well as open cholecystectomy. But not all open procedures were bundled, and some surgeons tried to bill for lysing the adhesions laparoscopically after converting the primary procedure to an open chole," Mueller says. She notes that such claims, even if paid, would almost certainly be noticed during a subsequent audit. "Formally bundling 44200 to these codes addresses this issue head-on."  
     
    CCI regularly issues new edits to reinforce existing coding guidelines, conventions and principles, Mueller agrees. She notes that until an earlier version of the CCI bundled 44200 to laparoscopic procedures, laparoscopic lysis of adhesions was (technically) separately payable when performed, for example, during the same session as a laparoscopic cholecystectomy. Such coding was nonetheless inconsistent with guidelines for analogous open procedures, which have long bundled lysis of adhesions to an open cholecystectomy (47600).
     
    Whether open or laparoscopic, if the lysis of adhesions requires significant additional time and/or effort, modifier -22 (unusual procedural services) could be appended to the appropriate primary code to gain additional payment, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.
     
    Claims submitted with modifier -22 should be accompanied by supporting documentation, Callaway says. She adds that the surgeon should increase his or her fee by an appropriate amount. Carriers may not pay the claim at a higher rate just because modifier -22 was appended.
     
    Callaway notes that most of the new edits involving 44200 include a "1" indicator. Therefore, in some cases, such as a procedure at a different anatomic site, or performed at a different time during the same day, 44200 (or any service or procedure with a 1 indicator) may be billed with certain descriptive modifiers to bypass the edit.
     
    According to a Medicare bulletin published by Blue Cross Blue Shield of Montana, the part B Medicare carrier in Montana, these include anatomic modifiers, such as -E1-E4 (eyelids, upper and lower left and right); -F1-F9 (right hand digits, four fingers left hand); -FA (left thumb); -LT (left side); -RT (right side), modifier -58 (staged or related procedure or service by the same physician during the postoperative period); modifier -78 (return to the operating room for a related procedure during the postoperative period); modifier -79 (unrelated procedure or service by the same physician during the postoperative period); and modifier -91 (repeat clinical diagnostic laboratory test).
     
    Modifier -59 (distinct procedural service), the modifier most often used to unbundle CCI edits, should only be used if no more specific modifier is appropriate. According to Medicare Montana, "If records do not support the use of the modifiers billed, recoupment action will be taken and postpayment monitoring may result." Other Medicare carriers likely adhere to similar policies, Callaway says.
     
    Note: If the CCI edit includes a "0" indicator, no modifier can bypass it.

    49002: "Nice" Code No Longer
     
    For general surgeons, the addition of 569 edits involving the reopening of a recent laparotomy is among the most significant changes in version 7.2. Surgeons were paid relatively well (17.85 relative value units [RVUs]) for this service, which usually accompanies a more significant procedure.
     
    That 49002 was separately payable when performed with primary procedures -- even though exploratory laparotomies are usually bundled with a primary procedure -- was justifiable, many physicians believed, because reopening a laparotomy can be significantly more complex than an exploratory laparotomy.
     
    "Once you commit to something in the abdomen, you pretty much lose 49000," Mueller says. Although there are exceptions (trauma patients, for instance), "Medicare may pay the lesser procedure [i.e., the 49000] when billed with, say, a splenectomy," she says. She adds that such claims almost always require review.
     
    "Code 49002 was a 'nice' code because it was paid. But now, by bundling 49002 with 569 codes, CCI has turned it into another 49000," Mueller says. She notes that virtually all the codes that now bundle 49002 are respiratory/cardiovascular (30000 series), digestive or genitourinary codes.
     
    As of July 1, therefore, 49002 is payable only when performed alone. Sometimes a laparotomy may be reopened without another procedure being performed, usually to control bleeding or contain an infection, which may involve making a new incision.
     
    Version 7.2 also bundles 49000 -- already bundled with most digestive surgery section codes -- with 144 new codes, of which only two -- 48550 and 48556, both pancreatic transplantation codes -- are in the 40000 series. The majority of the edits involve respiratory/cardiovascular system codes.
     
    Note: In some instances, particularly with vascular issues, 35840 (exploration for postoperative hemorrhage, thrombosis or infection; abdomen) may be used instead of 49002. For a detailed discussion of 49002 and 35840, see General Surgery Coding Alert, December 1999.

    Dermabond Code Bundled to Other Wound Repairs
     
    CPT 2000 clarified that repairs using tissue adhesives, such as Dermabond, should be reported using repair codes (12001-13160). The same year, however, HCFA (now the Centers for Medicare and Medicaid Services, or CMS) introduced a new code, G0168, to be reported if only tissue adhesives were used to close the wound or laceration.
     
    The new code was criticized by the American College of Surgeons (ACS), which, in a published letter to HCFA administrators, noted, "the creation of code G0168 & effectively overturns the decision of the CPT editorial panel that the existing repair codes should be used to report repairs performed with tissue adhesives. Through the CPT Assistant, the physician community has been educated to code in this manner." ACS also specifically noted that the usual steps preceding the introduction of a new code were not followed: Neither the AMA nor the ACS was consulted before the code was unveiled.
     
    The instruction to bill G0168 in place of existing CPT repair codes reduces payment to surgeons. According to the CMS physician fee schedule, G0168 is valued at 2.25 RVUs in an office setting and 0.71 RVUs in a facility (hospital) setting. But the lowest-valued repair code (12001) is valued at 3.72 RVUs (office) and 2.62 RVUs (facility).
     
    Medicare instructs surgeons to continue to report CPT repair codes if a combination of wound-closure adhesives and traditional methods (i.e., staples and sutures) are used. For this service, the appropriate CPT code, not G0168, should be billed to Medicare.
     
    CCI now bundles G0168 with more than 100 integumentary (10000 series) and musculoskeletal (20000 series) codes. Many of the edits appear to have been introduced to indicate a closure may not be required -- such as those involving paring or cutting of lesions, 11055-11057; skin biopsies, 11100-11101; removal of skin tags, 11200; shaving of epidermal or dermal lesions 11300-11313; or debridements (where the wound usually is left open to heal), 11010-11044. Other edits confirm that G0168 should not be billed if another procedure that already includes closure (such as excision of lesion), or describes a more extensive closure (such as adjacent tissue transfers, flaps and grafts) was also performed.
     
    Note: Code G0168 was already bundled with simple, intermediate and complex repair codes (12001-13160).

    97601: Only One Wound Care Service per Session
     
    CPT introduced 97601 in 2001. According to CPT Changes 2001: An Insider's View, 97601 should be reported by "nonphysician professionals (e.g., physician assistants, nurse practitioners, enterostomal therapy nurses, wound care nurses, physical therapists) licensed to perform these procedures, and [is] NOT reported in addition to codes 11040-11044. For wound debridement performed by providers other than nonphysician professionals [NPPs] [i.e., surgeons or other physicians], see 11040-11044."
     
    CCI version 7.2 now bundles 97601 with more than 500 codes, most of which are debridement, closure or excision codes. "Medicare does not want surgeons billing twice for the same service," Mueller says. "If the NPP performed a selective debridement and later the surgeon did a more extensive debridement or closed the wound, only the more extensive procedure should be billed."
     
    Code 97602 (removal of devitalized tissue from wound, nonselective debridement, without anesthesia [e.g., wet-to-moist dressings, enzymatic, abrasion], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session), which CPT introduced along with 97601, is unaffected. CMS considers this service incidental and not separately payable, and has never assigned it RVUs.
     
    The two codes differ in that 97601 describes a "selective" debridement, which usually involves cutting away devitalized tissue, whereas 97602 is "nonselective," which means tissue is softened and removed rather than cut away. According to CPT, "A greater set of skills is required to perform the selective debridement procedure" because "the cutting performed during selective sharp debridement at the border between the viable and necrotic tissue is much more likely to cause pain and bleeding than nonselective serial debridement."
     
    Because 97602 is nonselective, the surgeon is unlikely to have an NPP perform this service if a surgical debridement, excision of lesion or wound closure is also performed. This may explain why CCI did not bundle 97602 as it did 97601, Mueller says.

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