General Surgery Coding Alert

When complications occur during surgery, they often take extra time for the general surgeon to correct. But surgeons frequently dont know when or how to bill for that extra time. By using either modifier -22 (unusual procedural services) or -78 (return to the operating room for a related procedure during the postoperative period), surgeons can ensure they are reimbursed when complications arise.

Complications that are repaired during the original operative session should be billed by attaching modifier -22 to the primary procedure code. According to the national Correct Coding Initiative (CCI), general surgeons cannot bill separately for repairing complications that occurred during this procedure.

For example, during the course of a laparoscopic cholecystectomy (47563, laparoscopic cholecystectomy with cholangiography), a general surgeon lyses adhesions (44200, laparoscopy, surgical; enterolysis [freeing of intestinal adhesion][separate procedure]). During the course of the enterolysis, the surgeon notices a perforation of the small intestine that occurred during the lysis. He or she spends an additional 30 minutes repairing the perforation before proceeding with the cholecystectomy and cholangiogram.

Note: Surgeons should not bill lysis of adhesions with the cholecystectomy because the procedures are bundled. Also, please note that the CPT code for laparoscopic lysis of adhesions was changed to 44200 as of Jan. 1, 2000. The Health Care Financing Administration (HCFA) has established a grace period, however, until April 1, 2000, during which the old code, 56310, may be used.

No Separate Code

In this scenario, there is no separate code for repairing the complication that arose during the primary procedure. Consequently, the only way to get reimbursed for the extra time it took to lyse the adhesions and to repair the damage to the nicked bowel is to bill the laparoscopic cholecystectomy (47563) with modifier -22 attached.

The perforated bowel is not a mistake, but rather an unfortunate side effect of doing lysis of adhesions, says Terry Fletcher, BS, CPC, CCS-P, a coding and reimbursement specialist in Laguna Beach, Calif. Because a hole was inadvertently left in the bowel, it makes the procedure more complicated and longer to complete, so it is appropriate to bill for that extra time using modifier -22. If physician error causes the bowel perforation, the repair should not be billed, Fletcher adds.

Similar complications also may occur after the patient has left the operating room. For example, a woman may have a dermal inclusion or sebaceous cyst. When she sees a surgeon, he decides to remove it. The relatively routine procedure is complicated because the cyst is infected. Shortly after the procedure is completed, however, the woman returns because the wound is bleeding. The surgeon reopens the wound, fixes a blood vessel that was nicked inadvertently during the original surgery, and [...]