Code Cholecystectomy Surgeries With Confidence
Pay attention to NCCI edits before reporting additional procedures. In the U.S., approximately 20 million people have gallstones and an estimated 300,000 people have their gallbladders removed annually. The removal of a patient’s gallbladder is called a cholecystectomy. Providers have two ways to remove the gallbladder — laparoscopically or via open surgery. More than 90 percent of cholecystectomy procedures in the U.S. are performed laparoscopically. While gallstones are the most common reason for gallbladder surgery, there are other indications for this procedure, such as acute or chronic cholecystitis, choledocholithiasis, gallstone pancreatitis, gallbladder masses or polyps, bile duct obstruction, biliary dyskinesia (hypo and hyper function), nonfunctioning gallbladder, and porcelain gallbladder. Read on to learn the different laparoscopic cholecystectomy procedures and understand how to report the surgical procedures. Dissect the Gallbladder Removal Surgery During a laparoscopic cholecystectomy, the surgeon makes a small incision near the belly button. Then, the physician inserts a small tube into the incision and pumps carbon dioxide gas through to inflate your abdomen. Next, a separate incision is made, and the laparoscope is inserted. The laparoscope uses a small lighted camera to project images to a video monitor above the operating table. The surgeon uses a video monitor as a guide while they insert narrow surgical tools through another separate incision to remove the gallbladder. The surgeon then releases the gas from the abdomen and closes the incisions with stitches. This is a much less invasive procedure than an open procedure and takes about 60 to 90 minutes to complete, causing less pain and bleeding and leading to a quicker recovery time. Compare the Laparoscopic Cholecystectomy Procedure Codes The CPT® code book designates the following codes for laparoscopic cholecystectomy procedures: You’ll select a code from 47562-47579 if the provider uses surgical laparoscopy in various ways, depending upon the condition in the bile duct: If the provider uses a biliary endoscope, or choledochoscope, to view the common bile duct, report +47550 (Biliary endoscopy, intraoperative (choledochoscopy) (List separately in addition to code for primary procedure)). Try Your Hand at Coding the Following Scenarios Scenario 1: A 70-year-old patient is seen in the hospital for severe right upper quadrant pain. A surgeon performs a diagnostic laparoscopy. The provider confirms the presence of gallstones and decides to remove the gallbladder. Answer 1: Assign 47562 to report the laparoscopic gallbladder removal. Scenario 2: A 42-year-old patient with previous bile duct obstruction presents for laparoscopic cholecystectomy. The patient is prepped and anesthetized. The provider makes several small incisions, administers carbon dioxide, inserts the laparoscope, and visualizes the gallbladder. The physician then performs cholangiography by inserting a cholangiocatheter and injects contrast dye into the gallbladder. The surgeon looks for any abnormalities or stones present in the bile ducts. They then dissect the gallbladder and flush the site with saline solution. Answer 2: Use 47563 to report the cholangiography and gallbladder removal. However, if the provider administered indocyanine green (ICG) dye for the purpose of visualizing the common bile and cystic duct insertions to aid in dissection, this would not be considered an intraoperative cholangiogram, and you would code 47562 instead. Scenario 3: A 68-year-old patient presents with indications of intense pain in the abdomen radiating to the shoulder. The patient is also experiencing nausea and vomiting and clay-colored stools. The patient is appropriately prepped and anesthetized, and the provider makes an incision just below the gallbladder. Additional incisions are made for instrumentation and the introduction of carbon dioxide gas. Next, the laparoscope is inserted, and the gallbladder is visualized, structures surrounding the gallbladder are dissected, and the provider clips the cystic artery and duct. The surgeon explores the common bile duct to check for obstructions, and then dissects the gallbladder from the liver bed, which is the area of the liver against which the gallbladder rests. The physician flushes the site with saline solution and releases the carbon dioxide from the abdominal cavity, removes the instruments and tubes, checks for bleeding, and sutures the incision in the abdomen. Answer 3: Since the surgeon explored the common bile duct to check for obstructions prior to removing the gallbladder, you’ll report 47564 for the procedures. Scenario 4: A 55-year-old patient with previous abdominal surgery presents for laparoscopic cholecystectomy. The patient is prepped and draped. Anesthesia is administered. The provider makes an incision below the gallbladder. Additional incisions are made for instrumentation. Carbon dioxide is administered into the abdominal cavity. The provider inserts the laparoscope, but they are not able to view the gallbladder very well due to extensive adhesions. The provider decides to convert to an open cholecystectomy to remove the gallbladder. Answer 4: Use 47600 (Cholecystectomy) to report the gallbladder removal via an open surgical approach. Be Aware of Common Bundled Services The National Correct Coding Initiative (NCCI) manual for Medicare services contains important information about how to report laparoscopic cholecystectomy procedures. According to Chapter 6 of the manual, “If a diagnostic laparoscopy leads to a surgical laparoscopy at the same patient encounter, only the surgical laparoscopy may be reported.” The manual also states, “Neither a surgical laparoscopy nor a diagnostic laparoscopy code shall be reported with the open procedure code when a laparoscopic procedure is converted to an open procedure.” This direction is the reasoning behind assigning 47600 in Example 4 above. According to the manual, you cannot separately report a laparoscopic surgery if the physician performed the procedure to evaluate the surgical field or the extent of the patient’s condition. However, if the provider decided to perform an open surgery after reviewing the findings of a diagnostic laparoscopy, then you may report the diagnostic laparoscopy separately. “Modifier 58 may be reported to indicate that the diagnostic laparoscopy and non-laparoscopic therapeutic procedures were staged or planned procedures,” reports the NCCI manual. If a laparoscopic biopsy is performed for diagnostic purposes, and the provider decided to proceed with a laparoscopic cholecystectomy procedure based on the biopsy results, you’ll report 49321 in addition to the CPT® code for the laparoscopic cholecystectomy. “However, if the laparoscopic biopsy is performed for a different purpose such as assessing the margins of resection, CPT code 49321 is not separately reportable,” according to the manual. You may not separately report laparoscopic lysis of adhesions using 44180 (Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)) or 58660 (Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)) with other laparoscopic surgical procedures. Two codes that cannot be reported with a laparoscopic cholecystectomy procedure are 76000 (Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time) and 49400 (Injection of air or contrast into peritoneal cavity (separate procedure)). Code 49400 is integral to the procedure as it is required for the surgery to proceed. A Whipple-type pancreatectomy procedure (reported with codes 48150-48154) includes removal of the gallbladder. As a result, a cholecystectomy should not be reported separately. Identify the Correct ICD-10-CM Codes Be aware of your options when assigning your diagnosis codes for gallbladder procedures. The location, severity, status of acute or chronic, presence of obstruction and additional conditions offer greater specificity. Review your payer policies, such as Medicare’s local coverage determinations (LCDs) to confirm your diagnosis meets medical necessity. Lori Carlin, CPC, COC, CPCO, CRC, CCS, Principal at Pinnacle Enterprise Risk Consulting Services
