General Surgery Coding Alert

Relying on numerical order to ensure that you find the correct hemorrhoidectomy code? Watch out.

Starting Jan. 1, you won't always find specific codes where you expect them -- and using an unspecified code when a specific code is available could compromise your pay. That's why CPT 2010 introduces the new # symbol to alert you to an out-of-order code.

The "#" works like a flashing yellow light: Slow down, there might be something unexpected. Rather than moving groups of codes to new sections, the AMA has created another option. CPT will now resequence codes, in some instances, to avoid renumbering the codes, explained William T. Thorwarth Jr. MD, in "CPT 2010 Overview" at the CPT and RBRVS 2010 Annual Symposium's opening session in Chicago.

When you're coding a lesion excision, you usually assume the code number increases by one as the excision's size class goes up. But that truism will no longer hold true. Fortunately, watching for # will alert you to these inconsistencies

Example: The AMA wanted to break up the soft tissue neck excision parent code 21566 into two different size-based codes. Since 21566 is right next to 21567, there's no space for another code using numericalsequencing. Instead, the AMA chose available numbers that were close to those used so that the section reads:

• 21555 -- Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm

• #21552 -- ... 3 cm or less

• 21556 -- Excision, tumor, soft tissue of neck or anterior thorax, deep, subfascial, (e.g., less than 5 cm)

• #21554 -- ... 5 cm or greater

• 21557 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or anterior thorax; less than 5 cm.

"Before the new code symbol, we added a new symbol so you readily identify out-of-number codes," Peter A. Hollmann, MD, said in the symposium's final session of the day, "CPT 2010 Resequencing Principles."

The AMA's also got a new method of relocating an existing out-of-order code. Rather than deleting the code and creating a new number with the same or similar definition, the AMA will move the code to its more appropriate location and leave a road sign for you. "Where you would expect the code to be, we added references referring to the code's new place," Hollmann says.

Example: The definitions for hemorrhoid ligation and other anal excision procedures didn't change much, but due to a restructuring of the entire anal excision section to introduce systematic procedure classification, the codes fit better after 46200 (Fissurectomy, including sphincterotomy, when performed). So the AMA lists codes for the section in the following order and adds # signs in front of codes that are out of numerical order:

• 46221 -- Hemorrhoidectomy, internal, by rubber band ligation(s)

• # 46945 -- Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group

• # 46946 -- ... 2 or more hemorrhoid columns/groups

• # 46220 -- Excision of single external papilla or tag, anus.

• 46230 -- Excision of multiple external papillae or tags, anus

• # 46320 -- Excision of thrombosed hemorrhoid, external.

Identifying out-of-sequence codes with # isn't the only guidance CPT provides.

Numerical order reference helps out: If you turn in CPT 2010 to find any of the preceding codes in numerical order, you won't just find them missing. In their place you'll find a note that states: "Code is out of numerical sequence. See 46200-46288." This note serves as a roadmap to the restructured anal excision section so you'll know the new location for codes you've used in the past.

The new practice of resequencing instead of always replacing codes could save you lots of headaches. The old system required you to learn new codes and change paper forms and software when CPT deleted entire groups of codes and reassigned existing definitions to new numbers.

"Experienced coders who are already familiar the codes' organization and used to using the CPT book as a tool shouldn't find the resequencing too confusing," says Julia Appell, CPC, PCS, coder for General and Vascular Surgery PC in South Bend, Ind. "Having codes out of numerical sequence might muddy the water for coders who are just getting into it," so including training on this point will be important for new coders.

Because the AMA presented this as a new process for revising the code set, you need to be ready for more resequencing in coming years. Keeping up with the changes should be straightforward, "as long as CPT maintains the # identifier for out-of-sequence codes from year to year," Appell says.

CMS weighs in: In preparation for the new CPT resequencing practice, CMS addresses the issue in the 15.3 update of the Correct Coding Initiative (CCI) Policy Manual for Medicare Services (effective Oct. 1, 2009). Noting that "the sequence of codes as they appear in the CPT Manual does not necessarily correspond to a sequential numbering of codes," the policy manual states that its "use of a numerical range of codes reflects all codes that numerically fall within the range regardless of their sequential order in the CPT Manual." That means you'll need to use caution when you apply CMS instruction to ensure that you're addressing the proper codes.