General Surgery Coding Alert

Of the more than 4,700 changes to the national Correct Coding Initiative (CCI) this quarter (2,835 added edits and 1,908 deleted edits), several hundred will affect general surgical practice, the highlights of which include the bundling of cecostomy (enterostomy) to most pancreatic procedures and a newly bundled component for catheterization codes 93514-93533. CMS and the National Technical Information Services released CCI version 9.1 for April 1 to June 30, 2003.

CCI now officially bundles needle introduction to cardiac catheterization procedures, assigning the edits a "0" modifier indicator to confirm that the bundle applies in all circumstances and cannot be overridden. Specifically, version 9.1 includes 36100 (Introduction of needle or intracatheter, carotid or vertebral artery), defined as "a sheathed combination of needle and short catheter," as an integral component of left and combined left/right heart catheterizations 93514 and 93527. Similarly, the new CCI bundles 36200 (Introduction of catheter, aorta) to 93511-93524, 93527-93529 and 93531-93533.

The new edits now also include 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic or lower extremity artery branch, within a vascular family) in 93514-93529 and 93531-93533. But the edits involving 36245 include a "1" status indicator, meaning you may override the edit with modifier -59 (Distinct procedural service) if the needle/intracatheter placement occurs in a different location from the heart cath.

Asecond major group of edits involves the bundling of cecostomy/enterostomy code 44300 (Enterostomy or cecostomy, tube [e.g., for decompression or feeding] [separate procedure]) into almost all procedures involving the pancreas (48000-48100, 48120-48155, 48180, 48500-48510, 48520-48547 and 48554-48556). These edits also include a 0 modifier indicator, and therefore you may not unbundle them, regardless of circumstances. Rather, because CPT describes the cecostomy/enterostomy as a "separate procedure," it is considered incidental to all related procedures and must be the only procedure performed to warrant separate reimbursement, says Dennis Kelly, accounts receivable manager for CBS Surgical Group in Meriden, Conn.

Surgeons and coders should remember that when they report hemorrhoidectomy, coding guidelines dictate that simple ligature (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band]) is incidental to and not separately reportable from more complex excisions 46230-46258. In other words, you cannot claim 46221 and 46230, for example, during the same operative session. Code 46230 will always include 46221 because it is the "most extensive procedure." Version 9.1 of CCI now makes this bundling explicit Medicare policy.

CCI 9.1 also bundles liver biopsy 47000* (Biopsy of liver, needle; percutaneous) to more extensive excision procedures 47120 and 47125-47136. In effect, you may report a needle biopsy only if it is not followed by a more extensive excision. Similarly, you may not "add on" +47001 ( when done for indicated purpose at time of another major procedure [list separately in addition to code for primary procedure]) with more extensive excisions 47010-47015 and 47120-47136 because these are now bundled as well. "However," Kelly says, "it is still OK to bill 47001 with all other appropriate codes/major procedures, other than those listed in CCI. For instance, we will often bill 47001 with colectomies, cholecystectomies, etc."