General Surgery Coding Alert

Among the approximately 40,000 revisions in version 9.0 of the Correct Coding Initiative (CCI) are several thousand new edits that will directly affect surgical practice by limiting billing for injections, infusions and catheterizations with many hundreds of codes, as well as various edits affecting common surgical procedures.

CCI has followed revisions to the codes for excision of benign lesions in CPT 2003 with a host of new edits. Specifically, 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) now includes intermediate and complex repairs as described by 12031-12057 and 13100-13153, respectively. Excision codes 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) and 11440 (Excision, other benign lesion including margins [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) are subject to the same restrictions.

For Medicare payers and others who follow CCI, lesion excision of less than 0.5 cm includes all repairs, regardless of severity (note that the edits do not apply to excisions of more than 0.5 cm, e.g., those described by 11401-11406). Payers following CPT guidelines bundle only simple repair to lesion excisions.

The most numerous edits in version 9.0 involve the bundling of 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) to hundreds of surgical interventions, including many vascular (35001-36510 and others) and digestive system (40000 series) procedures.

CPT added 64416 for 2003 to distinguish continuous infusion from single injection as described by 64415* (... brachial plexus, single). As noted in the code descriptor, 64416 includes daily management of anesthetic agent as indicated by 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration), which you, therefore, may not report separately.

These edits which are too numerous to list and include procedures as varied as aneurysm or dissection repair (34831), thromboendarterectomy (35301-35381), endoscopies (43259, 43260-43272) and colostomy revision (44340), among others will prevent physicians from billing separately for continuous infusion nerve blocks with surgical procedures. Due to the sheer number of edits and because related codes 64415 and 64417* ( axillary nerve) have also been bundled extensively (although much less frequently than 64416) you should assume that CCI has bundled 64416 to most surgical procedures and report nerve blocks separately for Medicare payers only after consulting version 9.0 to be sure it is not included.

New-for-2003 artery exposure codes 34833 (Open iliac artery exposure with creation of conduit for delivery of infrarenal aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateral) and 34834 (Open brachial artery exposure to assist in the deployment of infrarenal aortic or iliac endovascular prosthesis by arm incision, unilateral) now include as integral and not separately billable needle introduction/ injection procedures 36000* (Introduction of needle or intracatheter, vein), 36002 (see below for more information on this code) and 36400 (Venipuncture, under age 3 years; femoral or jugular), as well as infusion code 37202. These edits like many of those described below are consistent with CCI policy, which has been to bundle minor "needle or catheter" procedures to most more-extensive services.

Another new code, 34900 (Endovascular graft replacement for repair of iliac artery [e.g., aneurysm, pseudoaneurysm, arteriovenous malformation, trauma]), also bundles 36000, as well as angiography procedures 35454 (iliac, open) and 35473 (iliac, percutaneous), physician-administered venipuncture (36410), transcatheter procedures 37202 (infusion other than for thrombolysis) and 37207 (placement of stents), and direct repair of lower-extremity blood vessel (35226).

CCI version 9.0 universally bundles 36002 (Injection procedures [e.g., thrombin] for percutaneous treatment of extremity pseudoaneurysm) to repair or excision and graft (35001-35162), arteriovenous fistula repair (35180-35189), blood vessel repair (35201-35281), thromboendarterectomy (35301-35361 and 35390), angioplasty (35450-35476), atherectomy (35480-35495) and bypass grafts (35500-35571), for a total of 102 new edits. All of the edits include a "0" modifier status indicator, meaning that you may not override the edits, regardless of circumstances.

In addition, CCI has bundled 36002 to bypass grafts (35582-35671), composite grafts (35681-35683), arterial transposition (35691-35695), all exploration/revision codes from 35700-35907, catheter procedures (36012, 36481-36510 and 36600-36660), hemodialysis (36810-36815) and cannula placement (36822-36823 and 36860-36861). Each of these edits, however, includes a "1" status indicator. Therefore, you may unbundle the edits using modifier -59 (Distinct procedural service) if the injection occurs in an anatomic area different from the more extensive procedure.

CCI now bundles 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]) to 48 codes. This code has been widely bundled in previous versions of CCI, and the new edits involve nearly all new-for-2003 codes in the 30000 and 40000 series, such as 34833, 34900, 43236 (Upper gastrointestinal endoscopy ... with directed submucosal injection[s], any substance) and others. Again, the number of edits involving 37202 (new and existing) precludes billing for the procedure under any circumstances for Medicare payers without first consulting CCI.

For 2003, CPT added six new codes to describe therapeutic apheresis (infusion of a patient's own processed blood), 36511-36516, each of which receives identical edits. In particular, physicians may not report E/M services (99201-99220, 99231-99285, 99291-99298, and 99301-99350) in addition to any of the apheresis codes. Rather, CCI considers the E/M integral to the apheresis procedure.

But these edits contain a "1" status indicator, suggesting that the surgeon may report an E/M service for an unrelated condition (or if the E/M service preceded and prompted the apheresis) by appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code and providing supporting documentation.

In addition to the E/M edits, several other codes, including 36000, venipuncture 36410 and transfusion 36430 and 37202 are bundled to 36511-36516 (note that these are minor "needle or catheter" procedures).

CCI 9.0 includes bundling edits involving +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]). In addition to the procedures with which you may not report 69990 separately, version 9.0 adds 34833-34900, 36416, 36511-36516, 36536-36537, 37182-37183, 37500, 38205-38215, 38242, 43201, 43236, 44206-44212, and new-for-2003 codes 45335, 45340, 45381, 45386, 46706, 49419 and 49904.

For an exhaustive list of edits, check the complete CCI, available from the National Technical Information Service (NTIS) at (800) 363-2068. Physicians and coders browsing the CCI should take special care to note any codes added to CPT for 2003. CCI 9.0 is the first version of CCI to include CPT 2003, and many edits are directly related to the new codes. For example, bone marrow or stem cell services (38204-38215) and vascular endoscopy (37500-37501), among others, have been subjected to numerous edits not covered here.