Get Paid for Laparoscopy Turned Open Using the Correct Modifier
Published on Tue Aug 01, 2000
Sometimes general surgeons begin a procedure laparoscopically, but decide to convert to an open procedure due to intraoperative findings. For general surgeons, this most often occurs during a laparoscopic cholecystectomy. Such a conversion, however, may also take place during any laparoscopic procedure, such as appendectomy, splenectomy, Nissen fundoplication, or hernia repair.
Correct Modifier Key to Payment
Although the coding guidelines for this situation are straightforward only the open procedure should be billed some general surgeons incorrectly code and bill for both the laparoscopic and open procedures by appending modifier -53 (discontinued procedure) to the laparoscopic procedure, which is never correct. Whereas others attach a modifier -22 (unusual procedural services) to the open procedure to reflect the additional time and effort involved in the conversion, which is occasionally correct, but only if the situation truly was unusual.
A typical scenario encountered by general surgeons proceeds as follows: A 70-year-old male with a history of gallbladder disease sees the general surgeon, who decides to perform a lap chole with cholangiography (47563, laparoscopy, surgical; cholecystectomy with cholangiography). Once the laparoscope is inserted, however, the surgeon finds the area that contains the gallbladder is severely inflamed and purulent. There also are gangrenous changes and initial dissection results in perforations causing bile spillage.
At that point, the surgeon quickly decides to convert to an open procedure (47605, cholecystectomy; with cholangiography), says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. In these situations, there is no reason to continue the procedure with the laparoscope, Dunaway says, noting that sometimes, you cant even see the gallbladder.
According to the national Correct Coding Manual, version 6.1 (April-June 2000), An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service; those procedures are considered sequential procedures. Only the CPT code for one of the services, generally the more invasive service, should be reported.
The same document also states, When an endoscopic service is attempted and fails, and another surgical service is necessary, only the successful service is reported. For example, if a laparoscopic cholecystectomy is attempted and fails, and an open cholecystectomy is performed, only the open cholecystectomy can be reported.
Many Medicare carriers also have local medical review policies (LMRPs) that address this issue and describe the two procedures (open and laparoscopic) as mutually exclusive. For example, Wisconsin Physician Service (WPS), the Medicare Part B carrier in Wisconsin, Illinois and Michigan, states that one reason procedures may be deemed mutually exclusive is if they represent two methods of performing the same service.
WPS then goes on [...]
