General Surgery Coding Alert

Often, coders rely on the CPT index when billing for reopening a laparotomy. The index directs them to 49002 (reopening of recent laparotomy). But under certain circumstances, they can use 35840 (exploration for post-operative hemorrhage, thrombosis or infection; abdomen) for the procedure and receive a slightly
higher reimbursement.

Using 35840Cardiovascular Section

Some coders maintain that if the laparotomy is being reopened because of bleeding or infection, the correct code should be 35840. Not only does it denote a higher level of specificity, they say, it also reimburses at a slightly higher rate.

For example, a patient with a history of diverticulosis (562.10) sees a general surgeon complaining of abdominal pain, and the surgeon performs a colonoscopy, which shows the patient has inflamed, irritated intestines. The surgeon decides to wait and watch, but two weeks later, the patient shows up in the emergency room doubled over in pain. When the surgeon is called in, he decides to perform an exploratory laparotomy, discovers that the intestines are very inflamed and showing signs of severe disease.

Based on these findings, the surgeon performs a colon resection (44140, colectomy, partial; with anastomosis).

Note: The exploratory laparatomy would be bundled into the colon resection.

Three days later, however, the patient complains about pain in the operative site and is running a fever. There also is redness around the wound. Consequently, the surgeon reopens the laparotomy to stop the infection.

Some coders may not use 35840 in this scenario because they are unfamiliar with the CPT manual, expert coders say.

Code 35840 is in the cardiovascular section, which at first glance would not seem to apply in the scenario outlined above. Instead, they may refer to the digestive system section because the laparotomy was performed on the intestines.

Coders dont go to the cardiovascular section because they look in the index, which takes them straight to the digestive system, says Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Phoenix, AZ. In fact, if you look up laparotomy in the CPT index, you will find 49002 in the exploration subsection, but no reference to 35840.

Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ, notes that 35840 is more specific and reimburses at a slightly higher rate. The reason for reopening the recent laparotomy is sometimes ignored and could be a vascular-related thing, such as a post-operative infection, thrombosis or hemorrhaging.

The lesson in all this, Cobuzzi says, is that coders shouldnt pigeonhole themselves in their own area of the CPT book.

What About 49002?

But not all coding experts agree that 35840 should be used in scenarios like the one above. Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist in North Augusta, SC, and the American Association of Professional Coders (AAPC) 1998 Coder of the Year, says that although she agrees that the CPT index is confusing and coders need to look beyond their specialties and go to other sections when necessary, in this particular instance she would code the reopening 49002.

I would look at the original surgery and ask What is the surgeon going back to investigate? In this case, the choice of code should be guided by the body area you originally treated; thats why the CPT is organized the
way it is.

In this case, Callaway-Stradley says the 35840 is in the cardiovascular section for a reason. It should be used for reopenings that need to be done for re-explorations of vascular procedures, while 49002, which is in the digestive section, should be used for re-explorations performed to correct abdominal procedures. She does concede that there is probably a lot of cross-over of payable diagnosis codes between the two, making it difficult for coders to distinguish between vascular and digestive complications.

But Callaway-Stradley also notes that, according to her research, the diagnosis codes that provide medical necessity for the 35840 include some that are vascular in nature, while those for the 49002 relate more specifically to the kind of problems more commonly faced by general surgeons doing procedures like the one described above. For example, in addition to codes for complications that are not organ specific, Callaway-Stradley links 35840 with ICD-9 code 997.2 (peripheral vascular complications; phlebitis or thrombophlebitis during or resulting from a procedure), whereas 49002 is linked to 997.4 (digestive system complications).

Callaway-Stradley also points to Medicares 1999 National Physician Fee Schedule Relative Value File, where the short description of 49002 is reopening of abdomen, while 35840 is explore abdominal vessels. This is another indication that 35840 is primarily intended for vascular complications, she says.

Although physicians always are instructed to code to the highest level of specificityand indeed 35840 does in fact specifically mention hemorrhage, thrombosis and infection, while 49002 does notother reference materials used regularly by coders do not draw significant distinctions between the two codes.

For example, Medicodes 1999 Coders Desk Reference (CDR) describes 35840 as follows: The physician reopens the original incision site and inspects the operative area for active bleeding, hematoma, thrombus and exudate. The physician removes or debrides any observed hematoma, thrombus and infected tissues. The physician looks for and corrects any active bleeding sites using electrocautery or ligation of bleeding vessels. The physician may leave an infected wound open, but generally closes the incision, leaving drains in place.

CDRs description of 49002 is quite similar: The physician reopens the incision of a recent laparatomy before the incision has fully healed to control bleeding, remove packing or drain a post-operative infection.

Although the description is shorter, both bleeding and infection are covered in CDRs description of 49002, leaving only thrombosis as the exclusive domain of 35840.

Note: According to Medicares 1999 National Physician Fee Schedule Relative Value File, 38540 has 18.75 RVUs, while 49002 has 18.01.

Findings Determine a Solution

Karen Evans, RN, CCS-P, a coding and reimbursement specialist in Mount Vernon, WA, says coders need to look at the findings before determining which of the two codes to use. If the surgeon re-explored the laparatomy, discovered a nicked artery that was bleeding and then controlled the hemorrhage, the 35840 would be more appropriate, Evans says, because the CPT description refers more specifically to hemorrhage and the injury is vascular. On the other hand, if the surgeon goes in and finds an abscess from the diverticulitis, he or she would use 49002. In short, Evans says she would use 49002 when the surgeon goes back to clean an infection, and 35840 to control a hemorrhage.

Because many of the same diagnosis codes provide medical necessity both for 49002 and 35840, either service is being paid by most carriers unless the physician needs to perform another procedure to repair the complication, in which case either would be bundled into that service.

Note: If the re-exploration occurs as a result of a complication, as it does in the scenario outlined above, modifier -78 (return to the operating room for a related procedure during the post-operative period) would have to be added to either the 49002 or 35840.