General Surgery Coding Alert

Bleeding control is just one use.

You just learned in “Solution 2” of the preceding article that the type of device used to control bleeding may point to a specific CPT^® code.

However, simply noting mention of a device in the op report, such as an endoclip, does not necessarily lead to a bleeding control code.

For instance: Surgeons may commonly use an endoclip to mark something in the gastrointestinal (GI) tract for future identification or imaging, but you shouldn’t use a bleeding control code in such a scenario.

Problem: Without a specific CPT^® code for marking with a clip, you’ll need to turn to an unlisted procedure code such as 43499 (Unlisted procedure, esophagus), 44799 (Unlisted procedure, small intestine), or 45399 (Unlisted procedure, colon).

Documentation: To ensure payment for an unlisted code, the surgeon must describe the service and the medical reason for it. “Add comment to the claim such as ‘application of endoclip for tissue marking,’” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel advisor for ASGE in Pasadena, California.

Remember: “If the person making the payment decision doesn’t understand what the physician did, your reimbursement probably won’t properly reflect the effort involved,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.