General Surgery Coding Alert

A distinct Dx goes a long way in proving the separate -- and separately payable --nature of appendectomy 

Commercial and Medicare payers frequently bundle appendectomy to other abdominal procedures the surgeon performs during the same operative session. But that doesn't mean you should -write off- every appendectomy as unreimbursable
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You can separately report --and be paid for --appendectomy if the procedure meets two requirements:

1. There is a documented problem with the appendix

2. Other procedures during the same session do not relate directly to the right colon.

Don't Expect Reimbursement for -Healthy- Removal

Here's an iron-clad rule: Medicare (and others) will not pay separately for the removal of a healthy appendix.

Surgeons may perform appendectomies (particularly on younger patients) during the course of more extensive abdominal procedures. Although this practice is less common now than in the past, many surgeons still remove a healthy appendix simply because they have already opened the patient and removing the appendix eliminates a potential subsequent health problem.

To avoid paying for removal of healthy appendixes, many carriers now want to see proof (such as an op report) that an appendectomy performed during the same session as another procedure was medically necessary.

Be Sure to Cite a Separate Dx

You should apply a separate diagnosis to prove to the payer that an appendectomy is medically necessary. If you cannot supply such a separate diagnosis, chances are that the removal isn't required because of immediate health concerns, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

Tip: If the surgeon doesn't have a specific diagnosis before opening the patient, you should report the applicable signs and symptoms. If the pathology report shows disease, provide that information as your primary diagnosis.

Example 1: The patient has a gallbladder or ovarian problem, and the surgeon finds appendicitis, as well. She then performs an appendectomy.

In this case, you should report +44955 (Appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure] [list separately in addition to code for primary procedure]) in addition to the primary procedure performed -quot; as long as there is a separate diagnosis (that is, appendicitis), sign or symptom, or pathology that relates specifically to the appendix.

Here's why: Note the use of -indicated purpose- in the descriptor for 44955. This means that there must be a separate, medically necessary diagnosis or signs and symptoms to justify the appendectomy, says Linda Martien, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla.

Example 2: A surgeon performs a diagnostic laparotomy to determine the source of a female patient's abdominal pain and finds a ruptured ovarian cyst on the left and an inflamed appendix on the right. The surgeon then performs a left oophorectomy (58940, Oophorectomy, partial or total, unilateral or bilateral) and also removes the appendix.

When the pathology report returns, appendicitis is indicated. Therefore, you may report the appendectomy using 44955 with a separate diagnosis of appendicitis (540-543, Appendicitis, as appropriate).

Alternative: Even if the pathology report returns negative for appendicitis, you can still report 44955 with solid documentation explaining that the appendix appeared diseased, Bucknam says.

-This takes you to an -other diseases of the appendix- diagnosis, but it is a totally legit reason to remove an appendix,- Bucknam says. -The doctor operated in a completely different location (left side as opposed to right), and the fact that the pathology didn't come back with a disease diagnosis doesn't negate the fact that the removal was for a specified reason.-

Example 3: Surgeons often remove the appendix during bariatric surgery (for example, 43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Roux-en-Y gastroenterostomy).

You may report removal of the appendix separately  -- as long as the surgeon encounters evidence of an inflamed appendix (in other words, medical necessity must support the appendix removal). Unless the appendix appears abnormal (with scarring and/or old inflammatory changes, for example), the removal is incidental to the surgery, and you should not report the appendectomy separately.

Recognize When Appendectomy Isn't Separate

Finding appendicitis in a patient during the course of another procedure is not a common occurrence, says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C.

More frequently, for instance, a patient may have a bowel obstruction and appendicitis (in fact, the appendicitis may be the cause of the bowel obstruction). If the obstruction requires a right colectomy (44140, Colectomy, partial; with anastomosis), you cannot separately report the appendectomy because the appendix is simply an extension of the cecum at the bottom of the right colon, and is therefore removed along with the rest of the resected colon.

In this case, the appendectomy is not a distinct, separately reportable procedure, but simply an included part of a more extensive surgery.

Consider Other Appendectomy Possibilities

Code 44955 is not your only choice for appendectomy. Depending on the circumstances, you may select from three additional codes:

- 44950 -- Appendectomy

- 44960 -- - for ruptured appendix with abscess or generalized peritonitis

- 44970 -- Laparoscopy, surgical, appendectomy.

You should select 44950 when appendectomy is the only procedure the surgeon performs during the session.

If the surgeon removes only the appendix laparo-scopically, you should instead select 44970.

Conversions Support Only 1 Code

Remember: If the surgeon begins a procedure laparoscopically and must convert to an open approach to finish, you can only report the successful (open) procedure.

This would mean that if the surgeon begins a laparoscopic appendectomy (44970) but, for patient safety or other reasons, must convert the procedure to an open appendectomy (44950), you should only report 44950.

In addition: When the surgeon converts from an endoscopic to an open procedure, you should attach V64.41 (Conversion of closed to open procedure, laparoscopic) as a secondary diagnosis, says Linda Martien, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla.

Important: You should report 44950/44970 only if the patient's appendix has not burst.

If the surgeon must remove a ruptured appendix, you should report 44960 (unless the surgeon also performs right colectomy, as described above). Code 44960 includes both the removal of the ruptured appendix and debridement and lavage of the area to make sure all infected tissue and fluid is removed.

When reporting 44960, you should attach a diagnosis relating to both the appendectomy (appendicitis) and debridement and lavage (peritonitis), Bucknam says.