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Missing modifiers could cost your practice.

Determining how to correctly code procedures from your general surgeon’s op report for an appendectomy can be difficult, but determining how to code services before and after the patient’s visit to the operating room (OR) can present even further challenges. Test your skills with the following appendectomy coding scenarios and decide how you would code each case. Remember to apply any modifier(s) that you think are necessary for accurate billing and reimbursement.

Concentrate on Procedural Differences When Choosing a Code

Scenario 1: The surgeon performed a laparoscopic appendectomy on a patient displaying symptoms of an inflamed appendix. The patient had been complaining of sharp navel pain that moved to the right lower quadrant of the abdomen, accompanied by nausea. In the course of the operation, it was discovered that the appendix had burst, causing widespread inflammation within the abdominal cavity. This led the surgeon to switch to an open procedure. The surgeon also carried out debridement and lavage to eliminate any infected tissue and fluid.

Answer 1: The codes for the two appendectomy methods — open or laparoscopic— are as follows:

• 44960 (Appendectomy; for ruptured appendix with abscess or generalized peritonitis)
• 44970 (Laparoscopy, surgical, appendectomy)

Take note: When a surgeon switches from a laparoscopic to an open procedure (or vice versa), you should report only the successful procedure. That means in this case, you would report the service using 44960 — the open procedure — and not 44970.

Because the appendectomy procedure for a burst appendix already involves debridement and lavage, you should not bill these services separately by using a code like 49084 (Peritoneal lavage, including imaging guidance, when performed), for example.

Don’t miss: To prove medical necessity and accurately portray the patient’s situation, you should first code the ruptured appendix using K35.200 (Acute appendicitis with generalized peritonitis, without perforation or abscess). Be sure to also list a secondary diagnosis of Z53.31 (Laparoscopic surgical procedure converted to open procedure).

Code This Surprise Bariatric Appendectomy

Scenario 2: While the surgeon was performing an open Roux-en-Y bariatric surgery procedure, the surgeon noted an inflamed appendix with scarring and had to perform an immediate appendectomy at the same time.

Answer 2: Because this is an open procedure, you should report the Roux-en-Y as 43846 (Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy). If the short limb is greater than 150 cm, you should instead report 43847 (… with small intestine reconstruction to limit absorption).

Because the surgeon noted an abnormality in the appendix, you should separately report that procedure as +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)).

Documentation: To prove the medical necessity for the appendectomy, you will need to list an appropriate diagnosis code based on the op note, such as K36 (Other appendicitis). Often, surgeons will remove the appendix as a secondary procedure during bariatric surgery, but this is not separately chargeable. The code +44955 should only be used when there are clear symptoms or pathological signs that justify the need for the procedure.

Don’t Miss the Modifier

Scenario 3: The surgeon performs an appendectomy for a patient with persistent right-lower-quadrant abdominal pain. The appendix is not infected or ruptured. A month later, the patient returns to the surgeon’s office complaining of acid reflux that is causing aspiration when lying down and interfering with sleep. The surgeon talks to the patient about the reflux symptoms and performs a physical exam. The note documents that the surgeon spends 24 minutes in preparation and seeing the patient to perform a history and examination related to the reflux complaint.

Answer 3: The correct code for the appendectomy is 44950 (Appendectomy). Because there is an absence of infection or rupture, you should not choose 44960 (Appendectomy; for ruptured appendix with abscess or generalized peritonitis).

E/M: The surgeon documents an office visit involving 24 minutes with an appropriate history and exam, so you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time on the date of the encounter for code selection, 20 minutes must be met or exceeded).

Even though the evaluation and management (E/M) service takes place within the 90-day global period for the surgery, it doesn't equate to a postoperative follow-up examination or care for a recent surgical wound. Rather, the purpose of the visit is to assess a distinct, unrelated health issue.

Do this: You should report 99213 with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period).

Keep in mind that in order to report modifier 24, the E/M service must meet these criteria:

• The E/M service must occur during the postoperative period of another procedure.
• The current E/M service must be unrelated to the previous procedure.
• The same physician (or tax ID or same group and specialty) who performed the previous procedure must provide the E/M.

Remember: Medicare and many other payers have very specific guidelines for what qualifies as “related” to the original procedure and what doesn’t. For instance, Medicare will almost always treat postoperative infections as related to (and therefore, included in the global surgical package of) the initial surgery.

Additional payment: Because you correctly applied modifier 24, your practice should receive an individual payment for the E/M service that the surgeon carried out during the surgical global period.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC