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 [...]