General Surgery Coding Alert

Unbundlingcoding for two or more procedures that should not be billed togetheris a major compliance problem. But many surgeons dont understand this concept, which can lead to claim denials. By reviewing the basic ideas behind bundling, such as mutually exclusive and component and comprehensive codes, general surgeons can avoid such problems.

By far the largest source of bundling combinations, or edits, is Medicares national Correct Coding Initiative (CCI), which has developed coding policies and more than 120,000 edits for reimbursement compliance to better control improper coding.

Although the CCI has been in place since Jan. 1, 1996, many general surgeons still do not understand its impact on how they bill procedures. This has serious compliance consequences because Medicare auditors may construe billing for procedures bundled into others as fraud.

Mutually Exclusive Codes

The CCI is particularly important to general surgeons because the billing for many of the procedures they perform is guided by its policies.

For example, the CCI edits include 47715 (excision of choledochal cyst) and 47716 (anastomosis, choledochal cyst, without excision) because they are considered mutually exclusive (i.e., these codes represent services that cannot reasonably be performed during the same operative session).

In other words, you cant excise a choledochal cyst and then bill the anastomosis of the same cyst without excision.

Component and Comprehensive Codes

Approximately 11,000, or just less than 10 percent, of the CCIs 120,000 edits are categorized as mutually exclusive. The other 90 percent may be categorized roughly as bundlescomprehensive codes that include component codes. Physicians may not bill the component codes if they also charge for the comprehensive procedure.

For example, code 36216 (selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family) includes code 36215 (selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family).

The 36215 cannot be billed together with the 36216, according to the CCI, because the surgeon has to thread the catheter through the first order arteries to access the second order. Therefore, the catheterization of the first order arteries is included in the second.

CCI further subdivides the comprehensive/component code category according to various principles used to determine the edit. These eight principles include:

1. CPT Definition. Some CPT codes are part of a series in which the first code becomes a component for the codes following it that refer back to the common portion of the procedure listed in the preceding entry. For example, 47600 (cholecystectomy) is followed by 47605 (with cholangiography). If the surgeon performs an open cholecystectomy with cholangiography, only 47605 may be billed because the 47600 procedure is a component of 47605 and appropriately bundled into that procedure.

2. CPT Manual Instructions/Guidelines. CPT also gives bundling instructions at the beginning of some sections in the manual. For example, in its introduction to codes for excision of benign lesions, CPT states, Excision is defined as full-thickness (through the dermis) removal of the following lesions and includes simple (non-layered) closure. When a surgeon excises a benign lesion (11420, excision, benign lesion, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less) and uses a simple closure (12001, simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), the closure may not be billed because it is a component of the lesion excision.

3. Sequential Procedures. Sometimes surgeons attempt a procedure and then switch to a more complex procedure (usually because they were unsuccessful with the former). For example, during the same operative session, the surgeon may attempt a needle biopsy of the breast (19100, biopsy of breast; needle core [separate procedure]) but is unable to obtain enough tissue. Consequently, he or she performs an incisional biopsy (19101, incisional). In this situation, the more extensive procedurethe incisional biopsywould be billed, but not the needle biopsy because 19100 is considered a component of 19101.

4. Separate Procedures. During a colectomy (44150, colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy), the surgeon may need to lyse adhesions (44005, enterolysis [freeing of intestinal adhesion] [separate procedure]). Because 44005 is a separate procedure, it cannot be billed separately in conjunction with a more comprehensive procedure, in this case, the partial colectomy.

5. Most Extensive Procedures. During a liver lobectomy (47130, total right lobectomy), the surgeon also may re-explore the operative wound to remove packing (47362, re-exploration of hepatic wound for removal of packing). Because the lobectomy represents a more extensive procedure than the re-exploration, 47362 is bundled into 47130.

6. With vs. Without Procedures. The only difference between 48150 (pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy [Whipple-type procedure]; with pancreatojejunostomy) and 48152 (without pancreatojejunostomy) is the fact that 48150 does not include the pancreatojejunostomy, while 48152 does. Therefore, billing for both codes at the same time makes no sense, and 48150 is considered a component code of 48152.

7. Standards of Medical/Surgical Practice. When a surgeon performs abdominal procedures, he or she should report other work that is done, such as exploration, as part of that procedure. For example, if the general surgeon excises a bile duct tumor (47712, excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic) and also places a stent (47801, placement of choledochal stent), the 47801 is a component code of the 47712 and may not be reported separately because the stent placement is standard practice when excising the tumor.

8. Misuse of Component Code With Comprehensive Code. Medicare uses this category when code bundling combinations dont neatly fit into any of the above categories. In essence, this category reaffirms that surgeons should not report component codes separately from comprehensive procedures. For example, the general surgeon performs a hepatotomy (47010, hepatotomy; for open drainage of abscess or cyst, one or two stages). Prior to that, he or she injected contrast dye into the patient to assess the abscess (49424, contrast injection for assessment of abscess or cyst via previously placed catheter [separate procedure]). In this situation, Medicare has determined that if the cyst (or abscess) is going to be drained, an assessment should be part of that decision. Consequently, 49424 cant be billed separately when the assessment is performed during the same operative session as 47010.

Note: There are three other subcategoriesanesthesia included in surgical procedures, laboratory panels and designation of sex proceduresby which component codes are bundled into comprehensive procedures, but these are not common to general surgery practices.

Judiciously Use Modifiers That Override Bundles

Most CCI edits may be overriden by modifiers to indicate that distinct or independent procedures were performed, and that billing with two codes that normally would be bundled is in fact appropriate because of special circumstances. Modifier -59 (distinct procedural service) was created as a response to the CCI edits and overrides most, but not all, bundling combinations. The CCI uses indicators to show which codes appropriately may use modifier -59 if documentation exists to support the claim that the procedure was distinct (which usually means it was performed on a separate site or at a different time during the same day).

Note: Medicare also has developed its own HCPCS modifiers to indicate procedures were performed on different sites on the body. These include -LT (left side [used to identify procedures performed on the left side of the body), -RT (right side), -E1 through -E4 (eyelids), -FA to -F9 (fingers and thumbs), -TA through -T9 (toes), -LC (left circumflex coronary artery), -LD (left anterior descending coronary artery), and -RC (right coronary artery).

Coding combinations when modifier -59 is inappropriate include those in the first category of CCI edits or those that are mutually exclusive. If the codes can be modified, they will have an indicator (1) beside them in the CCI. If they cant, indicator (0) is shown.

Surgeons may bill all the edits in the comprehensive/component category and its subcategories using modifier -59 when appropriate. They should keep in mind that using modifier -59 sends up a red flag for audit, however, so it should be used carefully and discriminately after ensuring that the appropriate documentation exists to back up the claim.

Note: For complaints about CCI edits, contact the provider relations staff of your local Medicare carrier. To order a copy of the CCI, contact the National Technical Information Service (NTIS) at 1-800-553-6847. The cost of an annual subscription is $260 for hard copy or CD-ROM versions.

Although the Correct Coding Initiative is important, it is not the only group of coding edits that Medicare uses. The Health Care Financing Administration (HCFA) instituted many edits before the CCI was established in 1996 and still enforces these. In addition, HCFA purchased a series of edits from HBO&C, which the agency refers to as commercial or proprietary edits and the rest of the coding world knows as black box edits because they are not published anywhere due to their proprietary nature.

Finally, general surgeons should remember that commercial carriers are not bound by and do not necessary follow the CCI, though they may use it selectively.

Editors Note: This article was prepared with the help of Emily Hill, PA-C, a coding and reimbursement specialist in Wilmington, N.C., and a member of the AMAs Correct Coding Policy Committee, and Susan Callaway-Stradley, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.