General Surgery Coding Alert

When billing for liver biopsies, coders must carefully read the operative report to bill correctly and obtain maximum reimbursement for their general surgeon. Because percutaneous liver biopsy is a commonly performed procedure, coders may automatically bill for it. Therefore, if their surgeon does not let them know that another type of biopsy was performed and if they do not read the operative note thoroughly, they would not know if the procedure that actually was performed should be charged at a much higher rate.

The following operative report is a good example because an unwary coder might incorrectly code not only the liver biopsy but also the right hemicolectomy indicated at the top.

Pre-operative diagnoses: Carcinoma of the cecum; submucosal mass of the transverse colon; chronic obstructive pulmonary disease (COPD); coronary artery and hypertensive heart disease with transvascular heart block.

Post-operative diagnoses: Same.

Procedures: Insertion of temporary transvenous pacemaker, insertion of left subclavian IV, right hemicolectomy, liver biopsy.

History: This 75-year-old man presented with severe anemia and was found to have a carcinoma of the cecum, along with a submucosal tumor in the right transverse colon. He also has a history of severe COPD requiring home oxygen and coronary artery disease with a right bundle branch block, left anterior hemiblock and delayed conduction through the left posterior bundle. He also has renal insufficiency and diabetes. He needs a temporary pacemaker in case the conduction becomes a complete block.

He also needs a subclavian IV for additional venous access. It is hoped that the submucosal tumor of the transverse colon can be removed with the standard right hemicolectomy.

Procedure: A thin wall needle was passed into the [patients] subclavian vein and a guide wire advanced. Initially, the guide wire would not advance and the vein was recannulated. Fluoroscopy showed good position in the chest ... The pacemaker wire was inserted through the introducer kit ... The generator was attached ... The pacemaker was turned off and left in place to be used if he developed a bradycardia. The introducer sheath was sutured in place and a dressing applied and wire taped
in place.

A left subclavian IV was then placed ... A small skin incision was made on the left side at the junction of the clavicle and first rib. The thin-walled needle was passed into the subclavian vein and a guide wire advanced. The dilator was then passed over the guide wire, followed by the triple lumen catheter. This was positioned just above the right atrium under fluoroscopy.

The abdomen was then prepped and draped. A supraumbilical transverse incision was made, extending from the right lateral abdomen to just across the midline and the abdomen entered. The abdomen was explored. The second mass seen on colonoscopy was palpated just to the right of the middle colic vessels. The omentum was taken off the colon with sharp dissection and electrocautery. The middle colic vessels were identified and the mesentery divided just to the right of the middle colic vessels down to the base of the omentum below the duodenum and pancreas.

The ileocolic vessels were identified and an avascular area in the ileum identified about 15 cm proximal to the ileocecal valve. The ileocolic vessels were clamped, divided and doubly ligated with 2-0 silk ligatures and the mesentery dissected out to the edge of the ileum. The hepatocolic ligament was then transected and the lateral peritoneal fold incised. The colon was reflected medially.

The duodenum was identified and kept posterior. The right colon and terminal ileum were thus freed up completely. The colon and small bowel were divided between Kocher clamps and the specimen removed. A functional end-to-end anastomosis was carried out, using the linear cutter on the antimesentric border of the colon and small bowel and the linear stapler across the open end of the bowel keeping the previoius staple lines apart. A good pulsatile blood flow was noted at the edge of both mesenteries and a patent anastomosis palpated ... The bowel was replaced in the abdomen.

The liver was inspected more closely and a couple of small white areas in the right lobe and left lobe of the liver identified. They didnt really look like metastases but I excised one for biopsy with electrocautery. The abdomen was again explored and hemostasis noted. The abdomen was then closed in layers.

Coding the Procedure

The procedure notes clearly indicate that the proce-dures performed are not necessarily those that might be inferred by a cursory scan of the top of the operative report, says Kathleen Mueller, RN, CPC, a coding and reimbursement specialist in the office of Allan K. Lieffer, MD, a general surgeon in Chester, IL.

According to Mueller, if the entire operative report was not read, a coder would not know how the liver biopsy actually was obtained. Many coders likely would bill using 47001 (biopsy of liver, needle; percutaneous; when done for indicated purpose at time of other major procedure [list separately in addition to code for primary procedure]) because it is the most frequent biopsy procedure performed. At the end of the procedural note, however, the surgeon clearly states that a portion of the liver was excised for biopsy with electrocautery.

The key word to note here is excised, which places the procedure squarely in the excision category of the liver section and distinguishes the procedure from the more commonly performed incisional biopsy. The procedure the physician actually performed is referred to as a wedge biopsy and should be coded 47100 (biopsy of liver, wedge).

This classification error has significant reimburse-
ment ramifications. The excisional biopsy (47100), which, unlike the 47001, is not an add-on code and reimburses at more than triple the rate of the needle biopsy. According to Medicares 1999 National Physician Fee Schedule Relative Value Guide, 47001 is assigned 3.50 relative value units (RVUs) while 47100 has 11.58. This means that a physician would receive about $120 for the 47001, but he or she would get reimbursed nearly $400 for the 47100.

Note: RVUs vary depending on the location of the provider.

Coders may fall into a similar trap when billing for the colectomy. At the top of the operative report, the surgeon notes that he or she performed a right colectomy. Although that is an accurate description, the surgeon may be unaware that CPT codes exist that specifically match the procedure performed.

In this instance, if the the surgeons procedure notes were not thoroughly read, the coder might bill for the colectomy with a 44140 (colectomy, partial; with anastomosis), Mueller says, because a right colectomy is indeed one type of partial colectomy. Unfortunately, in this case, it is the wrong one. The correct code for the procedure is 44160 (colectomy with removal of terminal ileum and ileocolostomy), which would have been clear had the coder read the section of the report in which the surgeon states that the duodenum was kept posterior and the right colon and small bowel were divided.

Because the 44140 has slightly more RVUs (32.57) than the 44160 (31.48), the coding error would not result in any significant reimbursement loss, but the classification error remains, which may make your practice liable for repayment at a later time. Further, a carrier may question the coding decision during an audit because physicians are expected to code to the highest level of specificity.

Billing for the remaining procedures is more straightforward, Mueller says. The subclavian IV should be coded 36489 (placement of central venous catheter [subclavian, jugular or other vein][e.g., for central venous pressure, hyperalimentation, hemodialysis or chemotherapy]; percutaneous, over age 2), and the insertion of the temporary pacemaker would take code 33210 (insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter [separate procedure]).

Correct Diagnosis Coding Crucial

The ICD-9 codes that should be used to indicate medical necessity for the procedures are as follows, Mueller says:

153.4malignant neoplasm of colon; cecum; ileocecal valve;

235.3neoplasm of uncertain behavior of digestive and respiratory systems; liver and biliary passages;

426.54trifascicular block; and

459.89other unspecified disorders of circulatory
system; other; collateral circulation [venous], any site; phlebosclerosis; venofibrosis.

She also notes that because the surgeon used fluoroscopy and refers to it twice in the procedure note concerning the temporary pacemaker and subclavian IV insertions, the radiology code 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034) may be billed.

Modifier -26 (professional component) should be attached to the 76000 because the surgeon does not own the fluoroscopy equipment at the hospital, Mueller adds.