General Surgery Coding Alert

Plus, learn endoscopic and bone marrow limitations.

Keeping up with Correct Coding Initiative (CCI) quarterly updates to the edit-pair lists will only get you so far in Medicare billing compliance. You also need to study guidance that CMS puts out in the National Correct Coding Initiative Policy Manual, the latest being a Jan. 2012 update that could have significant impact on your general surgery practice.

We've got the lowdown on a few important changes that are sure to affect the way you code your services, thanks to coder Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Auditing and Coding, and senior coder and auditor with The Coding Network, who broke down the changes.

Background: Each year, CMS updates the Policy Manual, which offers rationale for various CCI edits, as well as describing acceptable scenarios for overriding some edit pairs.

Bundle Imaging Into These Services

When it comes to emergency endotracheal intubation procedures (31500), Swan-Ganz catheter insertions (93503), and chest tube insertions (32422, 32550, 32551), your surgeon is most likely accustomed to performing a post-procedural x-ray to determine that the tubes are in the correct position. However, because CMS considers that imaging to be typically associated with the procedure, the CCI has included the imaging payment into the RVUs for the insertions.

"A chest radiologic examination CPT® code (e.g., 71010, 71020) should not be reported separately for this radiologic examination," the Policy Manual states with regard to these post-procedure x-rays.

That's not all: The Policy Manual discusses other imaging restrictions, such as not reporting +76937 (Ultrasound guidance for vascular access ...) in addition to 36147 (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/ fistula) ...). Similarly CMS says you should not separately report operative angiograms or venograms performed as part of percutaneous interventional vascular procedures using diagnostic codes (such as 75820, Venography, extremity, unilateral, radiological supervision and interpretation).

Override option: According to CMS, you're justified in reporting the venogram or angiogram separately only if, on the date of the interventional procedure, "it is medically reasonable and necessary to repeat the [prior venogram or angiogram] study to further define the anatomy and pathology." Then, you should "report the repeat angiogram with modifier 59 [Distinct procedural service]." The Policy Manual goes on to state that, "if it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 [Reduced services] to the angiogram CPT code."

Watch Bone Marrow Boundaries

When a surgeon performs a bone marrow aspiration and biopsy for the same patient on the same day, the Policy Manual update has a lot to say about how you report those services:

• When the surgeon performs bone marrow aspiration alone, the appropriate code is 38220 (Bone marrow; aspiration only).
• When the physician performs bone marrow biopsy alone, the appropriate code is 38221 (Bone marrow; biopsy, needle or trocar).
• When the physician performs bone marrow aspiration and biopsy at separate sites or separate patient encounters, you may report 38220 and 38221 together. "Separate sites include bone marrow aspiration and biopsy in different bones or two separate skin incisions over the same bone," states the Policy Manual. If the two procedures meet one of these criteria, you may override the edit by appending modifier 59 (Distinct procedural service) to 38220 and receive payment for both services, says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

When the physician performs bone marrow aspiration and biopsy at the same site through the same skin incision, you should not report 38220 in addition to 38221. Instead, you should report 38221 and G0364 (Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service) to Medicare payers.

Obey other aspiration limits: The Policy Manual also states that you should not list 38220 with "a spinal osteotomy, vertebral fracture repair, spinal arthrodesis, spinal fusion, laminectomy, spinal decompression, or vertebral corpectomy CPT code if the bone marrow aspiration is obtained from the surgical field." If the aspiration is from a distinct anatomic site, however, the manual states that "it may be reported separately with an NCCI-associated modifier."

Include Organs in Pelvic Exenteration Charge

If your surgeon performs a pelvic exenteration procedure that you report with a code such as 45126 (Pelvic exenteration for colorectal malignancy, with proctectomy [with or without colostomy], with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube[s], with or without removal of ovary[s], or any combination thereof), you should not separately code for the individual removal of organs listed in the exenteration procedure, according to the Policy Manual update.

Official wording: The update states, "Pelvic exenteration procedures (CPT codes 45126, 51597, 58240) include extensive removal of structures from the pelvis. Physicians should not separately report codes for the removal of pelvic structures (e.g., colon, rectum, urinary bladder, uterine body and/or cervix, fallopian tubes, ovaries, lymph nodes, prostate gland)."

Pay Attention to Endoscopic Guidelines

Sometimes gastroenterologic endoscopic procedures include complementary services. Make sure you adhere to the guidance established in the latest Policy Manual update concerning these services.

Esophageal and gastric washings for cytology (such as 43753-43754, Gastric or Duodenal intubation and aspiration ...) are integral components of an upper gastrointestinal endoscopy (such as 43235, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), according to the update.

Do this: "Gastric or duodenal intubation with or without aspiration ... should not be separately reported when performed as part of an upper gastrointestinal endoscopic procedure," the manual states.

To read the complete updated Policy Manual, visit www.cms.gov/NationalCorrectCodInitEd.