General Surgery Coding Alert
CPT 2003 Brings Big Changes, Important New Codes and Numerous Refinements
Changes in CPT 2003 will allow surgeons to include margins when measuring lesion size, thereby increasing the total area of all excisions reported. Other revisions to CPT for 2003 include several important new codes to identify services previously reported with "unlisted procedure" or imprecise substitute codes, as well as text clarifications that alter previously established coding principles. Lesion Removal: Measure Those Margins Perhaps the most significant changes to CPT 2003 for general surgery coders are guideline revisions for measuring and reporting lesion removal. Previous CPT editions have allowed surgeons to report removals according to the size of the lesion only, rather than based on the size of the area actually removed. The CPT changes probably won't result in increased payments, however. Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM Program Coordinator at Clarkson College in Omaha, Neb., predicts either that CMS will reduce the fee schedule value for the lesion codes or that it will issue instructions to continue to report only lesion size (not including margins) for Medicare carriers. Alternatively, CMS may develop dedicated HCPCS codes for lesion removal for Medicare carriers. Look to future issues of General Surgery Coding Alert for more information as it becomes available. New Lap Codes Replace Unlisted-Procedure Code In another important move, CPT 2003 adds six new codes to describe laparoscopic colectomy. These codes represent the laparoscopic equivalent of several already-established open procedures: These new codes will reduce dependence on unlisted-procedure codes such as 44209, says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. In a closely related move, CPT 2003 has eliminated unlisted-procedure code 44209. In its place, CPT offers two new unlisted-procedure codes: 44238 (Unlisted laparoscopy procedure, intestine [except rectum]), which is a direct replacement for 44209, and 44239 (Unlisted laparoscopy procedure, rectum) to report any laparoscopic procedure of the rectum without a dedicated code. Even with the addition of the six new lap cole codes, not every open colectomy procedure has a laparoscopic equivalent. For example, no laparoscopic code mirrors 44141 (Colectomy, partial; with skin level cecostomy or colostomy), so you should report 44238 if the surgeon performs partial colectomy with skin level cecostomy or colostomy laparoscopically. CPT adds a new code (+44701, Intraoperative colonic lavage [list separately in addition to code for primary procedure]) to describe colonic lavage, a recently developed on-table preparation technique that allows a surgeon to perform a single-stage colon resection without colostomy. According to CPT, 44701 is an add-on procedure for use with 44140, 44145, 44150 or 44604 only, as appropriate. Take Heart: New/Revised Vascular Repair Codes CPT 2003 revises and adds several codes to describe endovascular repairs of abdominal aortic aneurysm(s). First, the descriptor for 34812 (Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral) omits "aortic" as used in 2002, thus broadening the code and allowing you to use it with new code 34900 (see below), according to CPT Changes 2003: An Insider's View. Similarly, 34825 (Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel) now describes placement of extension prosthesis in both the aortic and iliac arteries, rather than the aortic artery only, as in previous years. 'Miscellaneous Services'Codes May Not Pay CPT 2003 also introduces two "Miscellaneous Services" codes, although Medicare probably won't pay for them, speculates Douglas Jorgensen, DO, CPC, a practicing physician in Manchester, Maine, and chairman of the Osteopathic Medical Economics Committee: Even if Medicare denies these codes "on the same basis as the after-hours codes [99050-99054] [i.e., the service is included in any E/M services provided], there's still a chance that some private insurers may reimburse for them," Jorgensen suggests. And CPT adds 99600 (Unlisted home visit service or procedure) to report an otherwise unlisted visit or procedure provided in the patient's home. This code joins 19 revised codes (99551-99569) to describe home infusion procedures or services (for example, 99552, Home infusion for pain management [epidural or intrathecal], per visit). Report Endovascular Therapy More Precisely CPT now differentiates temporary and permanent vascular occlusion, adding 61623 (Endovascular temporary balloon arterial occlusion, head or neck [extracranial/ intracranial] including selective catheterizationof vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion) and revising 61624 (Transcatheter permanent occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; central nervous system [intracranial, spinal cord]), which previously specified only "transcatheter occlusion or embolization." Next month: More code additions and revisions from CPT 2003.
Specifically, CPT now instructs physicians and coders to choose codes for removal of benign (11400-11446) and malignant (11600-11646) lesions by "measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter)" [emphasis added]. Note that the physician should measure the lesion and margin prior to excision because pathology specimens generally shrink in the laboratory and therefore will not provide appropriate dimensions.
Two new codes apply for artery exposure. Code 34833 (Open iliac artery exposure with creation of conduit for delivery of infrarenal aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateral) describes suturing a segment of synthetic conduit to the iliac artery, as well as subsequent termination of the conduit following deployment of an endograft. Meanwhile, 34834 (Open brachial artery exposure to assist in the deployment of infrarenal aortic or iliac endovascular prosthesis by arm incision, unilateral) describes creation of a conduit for access through the brachial artery during endovascular therapy.
You may report 34833/34834 in addition to endovascular repair, e.g., 34800-34804. According to CPT Changes 2003, "The stand-alone status of these codes (as opposed to add-on) reflects the fact that exposure of the artery and the attachment and termination of the conduit through which manipulations will be done are not related to the target location of the prosthesis the prosthesis type or the artery repair, and therefore are not an included service within these procedures."
CPT 2003 adds 34900 (Endovascular graft replacement for repair of iliac artery [e.g., aneurysm, pseudoaneurysm, arteriovenous malformation, trauma]) to report the surgeon's replacement of an endograft in the iliac artery in the same manner that 34800-34804 describe endograft placement in the aortic artery. You need no longer report such an endovascular procedure which is less invasive than the analogous open procedure (35131) with an unlisted-procedure code. Note that 34900 includes all angioplasty (balloon dilation) or stent deployment related to the endograft placement. 
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