General Surgery Coding Alert

Understand modifier 51 use.

You have your answers for coding the Crohn's surgical case described in first article, now see how they stack up to our experts' coding:

Procedure:

• 44204 (Laparoscopy, surgical; colectomy, partial, with anastomosis)
• 44202 (Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis)

Diagnosis:

• K50.812 (Crohn's disease of both small and large intestine with intestinal obstruction)
• K50.818 (... with other complication)

Code Multiple Scopes

If you decided to report just one procedure code for this case, such as 44204, you'd stand to lose a lot of pay.

In many circumstances, you can separately report multiple surgical laparoscopic procedures that your surgeon performs during a single operative session.

Myth: Some coders believe that the op report must document separate incisions before you can code multiple scopes, but that's simply not true, according to Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

If you check Correct Coding Initiative (CCI) edits, you'll see that there's no restriction against reporting together 44204 and 44202.

Caution: You will find a few surgical scopes subject to edits, however, such as 44970 (Laparoscopy, surgical, appendectomy), which CCI bundles with many other surgical lap procedures. That means you should always check CCI edits before you bill multiple scopes.

Never diagnostic: If you added 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to your billable codes for this Crohn's case, you would be wrong. You should never report a diagnostic scope in addition to a surgical scope for the same surgery, because the surgical procedure pay includes the diagnostic scope.

Understand Modifier 51 and Multiple-Scope Pay

Although you should report both scopes in this case, you won't get paid the full amount for each procedure. Instead, you should expect the payer to apply a multiple-procedure payment reduction on the second scope.

How it works: Payers fully reimburse the procedure with the highest relative value units (RVUs). That's 44204 in this example, which pays $1605.22 (2018 physician fee schedule national facility amount, conversion factor 35.9996). The payer should also cover 50 percent of the payment for the lower-priced service, 44202, which will be $722.15 (half of $1444.30, 2018 physician fee schedule national facility amount, conversion factor 35.9996).

What about modifier 51? "The function of modifier 51 is to identify the additional procedures or services being performed at the same operative session, by the same individual provider, as the primary procedure or service," says Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC, in Indianapolis.

Surprise: Many payers don't want you to assign the modifier. For example, Medicare doesn't recommend reporting modifier 51 on your claims, says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions Coding Quality and Education Department.

Instead, CMS's processing system will append the modifier to the correct procedure code as appropriate. Many other payers perform similar automation to determine which procedure earns the multiple-scope payment reduction.

Tip: You should never append modifier 51 or expect payers to use the multiple-scope formula to reduce pay for the following codes:

• Add-on codes, which the CPT^® manual lists in Appendix D and identifies with a + symbol in the code set
• Codes in Appendix E of the CPT^® manual, which lists modifier 51-exempt codes, which are marked with a ¡ symbol in the code set
• Codes that have modifier 50 (Bilateral procedure) appended, and therefore already have a fee reduction
• E/M services

Zero in on Diagnosis Coding

If you reported a diagnosis code such as K56.60 (Unspecified intestinal obstruction) or K63.1 (Perforation of intestine (nontraumatic)), to describe the intestinal obstruction and perforation in this case, you would be wrong. In fact, an Excludes 1 note under K56.60 prohibits this code for "intestinal obstruction due to specified condition," and instructs you to "code to condition."

Instead: Because the patient has a Crohn's diagnosis, you must code Crohn's with the appropriate complication(s). The correct codes are K50.812 for the intestinal obstruction complication, and K50.818 for the bowel perforation complication.

Deconstruct code: K50.8- indicates that the patient has Crohn's disease of both the small and large intestine. The fifth character signifies no complication (0) or presence of complication (1). The sixth character identifies the type of complication, such as obstruction (2) or fistula (3).