General Surgery Coding Alert

Bundling rules restrict separate lysis-of-adhesions coding.

When your surgeon cuts through adhesions during abdominal surgery, is there any way for you to ethically capture pay for the extra work?

The answer is a qualified "yes," according to our experts. Read on to learn the circumstances that warrant additional billing, and the coding methods to capture adhesiolysis pay.

Recognize Conditions for Separate Enterolysis

Although CPT® provides the following two codes for adhesiolysis, "separate procedure" rules and Correct Coding Initiative (CCI) edits bundle the service with most abdominal surgeries:

• 44005 -- Enterolysis (freeing of intestinal adhesion) (separate procedure)
• 44180 -- Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure).

Those restrictions mean that you should separately report freeing of intestinal adhesions only under three circumstances:

1. Enterolysis is the only procedure your surgeon performs during the operative session

2. The adhesions are in a different anatomic site or surgical session from the primary procedure

3. The lysis is extensive and requires much more time and effort than is typical for the primary procedure.

Caveat: Although CPT® identifies number 3 (above) as an appropriate condition for reporting a separate adhesiolysis code, Medicare and most other payers won't allow you to bill separately when the surgeon performs enterolysis in the same area as the primary procedure. Read on to see how a modifier can help when adhesiolysis requires extensive additional work.

Master Methods to Capture Enterolysis Pay

If CCI edits bundle the primary procedure with the appropriate enterolysis code 44005 or 44180, you can only override the edit pair if the surgeon performs the lysis of adhesions at a different anatomic site or during a different operative session. In those cases, you can report the primary procedure code (such as 43415, Suture of esophageal wound or injury; transthoracic or transabdominal approach) with 44005-59 (Distinct procedural service) to override the edit pair.

Caution: Many abdominal procedures that CCI bundles with 44005 and 44180 have a modifier indicator of "0," meaning that you can't unbundle the edit pair under any circumstances.

Turn to 22: If you can't bill the enterolysis with a separate code, but your surgeon documents extensive additional work for the adhesiolysis, you might be able to capture the extra work using modifier 22 (Increased procedural services).

You can only make the case for using modifier 22 "when the adhesions represent a significant amount of work, not when the lysis is done simply to access the surgical site," says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

Documentation should describe adhesions that are dense, very adherent, and have a blood supply, for instance. The surgeon should also document the significant work associated with the adhesion removal, using sharp dissection and sometimes laser, for instance. Don't forget to report the amount of time that the work added to the operative session, Witt adds.