General Surgery Coding Alert

Don’t lose $241 with this one little mistake.

Reporting appendectomies can be an obstacle course of potential pitfalls and missed opportunities. Make sure you get off the course intact, with all the pay you deserve, by following our expert’s three tips.

Bonus: Check out the handy Clip-n-Save Tool for a flowchart to guide you to the correct code choice.

Tip #1: Give a Wide Berth to ‘Healthy’ Appendix Removal

If your surgeon removes a healthy appendix — or simply forgets to document symptoms or pathology that led to the removal — you can kiss any payment for the service goodbye.

Whether the appendectomy is a stand-alone procedure or performed with another abdominal surgery, you’ll need to justify “medical necessity” if you want to get paid. That means you should look at the op report to determine why your surgeon removed the appendix, and you should also mine the pathology report for documentation if it’s available at the time of billing.

A diagnosis that demonstrates the reason for the appendectomy could be signs and symptoms that led to the procedure, such as right lower quadrant abdominal pain (R10.31, Right lower quadrant pain). Or the surgical or pathology report might document a definitive diagnosis such as one of the following code families in ICD-10:

• K35.- — Acute appendicitis… - report one of these codes for acute appendicitis
• K36 — Other appendicitis use this code for other, chronic, or recurrent appendicitis
• K37 — Unspecified appendicitis - report this code for unspecified appendicitis
• K38.- — select one of the following codes for other diseases of appendix, such as

o    K38.0 Hyperplasia of appendix
o    K38.1 Appendicular concretions
o    K38.2 Diverticulum of appendix
o    K38.3 Fistula of appendix
o    K38.8 Other specified diseases of appendix
o    K38.9 Disease of appendix, unspecified

Tip #2: Target Correct ‘Stand-Alone’ Code

If the surgeon performs a primary appendectomy, you should choose one of the following codes:

• 44950 — Appendectomy
• 44960 — ... for ruptured appendix with abscess or generalized peritonitis
• 44970 — Laparoscopy, surgical, appendectomy

Choose 44950 or 44960 for an open primary appendectomy. You’ll reserve 44960 for cases with a ruptured or perforated appendix and/or generalized (diffuse) peritonitis, such as demonstrated by ICD-10 code K35.2 (Acute appendicitis with generalized peritonitis).

Don’t miss: Failure to document rupture or widespread peritonitis could cost your practice $240.61. That’s the difference between 44960 pay ($908) and 44950 pay ($667.39) (2016 Physician Fee Schedule [PFS] national facility amounts, conversion factor 35.8043).

Problem: CPT^® doesn’t provide a distinct code for a laparoscopic appendectomy of a ruptured appendix — should you use 44960 for all rupture appendix procedures?

“No — you should reserve 44960 for an open procedure,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Do this: “Report 44970 for a primary laparoscopic appendectomy whether or not the appendix is ruptured,” Bucknam says. “If the surgeon documents additional work because of a rupture or diffuse peritonitis, you can append modifier 22 (Increased procedural services) to the code and bill for the additional work.”

Tip #3: Don’t Miss Add-On Appendectomy

Many coders have it drilled into their heads that they can’t report an appendectomy when done at the same time as another major abdominal procedure. That might be true — sometimes.

“If the surgeon removes the appendix incidentally, you should not separately code the work,” Bucknam says. “But if the surgeon documents a distinct problem with the appendix, you can separately bill for the appendectomy.”

Caution: Don’t use one of the codes 44950-44960 for an open appendectomy with another abdominal procedure. Instead, report +44955 (Appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure] [List separately in addition to code for primary procedure]). Billing 44950 or 44960 for an additional appendectomy would result in serious overpayment, since +44955 pays only $87.36 (PFS national facility amount, conversion factor 35.8043).

For instance: While performing gallbladder removal for a patient, your surgeon visualizes acute appendicitis and performs an open appendectomy. In this case, you should report +44955 in addition to the code for the cholecystectomy (such as, 47562, Laparoscopy, surgical; cholecystectomy).

If the appendectomy in the above example were laparoscopic, instead of +44955, you should report 44970 with modifier 59 (Distinct procedural service) or other appropriate modifier. “Expect the payer to impose a multiple-procedure payment reduction on the second scope,” Bucknam says.

Here’s why: Correct Coding Initiative (CCI) bundles 44970 as a column 2 code with 47562 and many other abdominal procedures. The modifier indicator of “1” means that you can override the edit pair if the surgeon performed the appendectomy as a separate procedure. The appendectomy qualifies as a separate procedure if the case meets one of the following criteria:

• the appendectomy is in a different location from the other procedure
• the appendectomy occurred at a different session than the other procedure
• one procedure led to the decision to perform the second procedure.