General Surgery Coding Alert

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 to use the 47605 and 47563 as an example of mutually exclusive codes. These procedures represent different methods of accomplishing a cholecystectomy with cholangiography. Thus, to report both a laparoscopic and an open surgical approach to accomplish the same clinical outcome represents duplicity of efforts and overlapping of services.

Modifier -53 Does Not Apply

In spite of these guidelines, some surgeons may be confused about how to code the conversion from laparoscopic to open procedure, particularly if a significant amount of time was spent before the decision to open the patient was made. If coders, in turn, are unaware of the guidelines, they may sometimes resort to using alternative (and inappropriate) coding strategies to gain additional reimbursement.

One such strategy is to bill for both the laparoscopic and open procedures, with modifier -53 attached to the laparoscopic service. While some coders report that their carrier pays such claims, they are clearly inappropriate and should not be used, coding experts say.

The CPT descriptor for modifier -53 states, Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Such circumstances include potentially life-threatening situations, such as uncontrollable bleeding, hypotension, neurologic impairment or cardiac arrest.

Modifier -53 should not be used if the surgeon successfully completes the service (i.e., the cholecystectomy), even if another technique is used, says Elaine Elliott, CPC, a practice coder with Treasure Coast Surgical Group, a seven-physician practice in Stuart, Fla. As long as you continue on and successfully complete the service, you bill for that service only.

Judy Breuker, CPC, CCAP, CCS-P, an independent coding and reimbursement specialist and an executive officer of the national advisory board of the American Academy of Professional Coders, agrees. Modifier -53 does not apply to the conversion of a laparoscopic procedure to an open one. It should be used only when the well-being of the patient is threatened.

The fact that some carriers may be paying such claims, even if they do so repeatedly, does not mean they have been billed or coded correctly. At the very least, if the surgeons practice is audited, such payment may need to be refunded.

Use Modifier -22 Only in Special Circumstances

Another strategy used by coders to gain some extra reimbursement for their surgeons who convert a laparoscopic procedure to an open one is to bill only for the open procedure, as per the guidelines quoted above, but with a -22 modifier attached.

Modifier -22, however, should be used only if the documentation indicates that the open procedure was significantly more difficult than usual, Breuker says. The fact that the procedure was converted from laparoscopic to open isnt enough, she says, noting that the implication of the guidelines quoted above is that you shouldnt charge more simply because of the conversion.

In the example given earlier, appending modifier -22 to the open cholecystectomy with cholangiography would not be appropriate, because the surgeon made the decision to switch shortly after beginning the lap chole.

Sometimes surgeons work for a significant amount of time before deciding to abandon the laparoscopic approach for an open procedure. For example, the patient may present with an inflamed gallbladder, which the surgeon believes can be removed laparoscopically. At first, while the surgeon is working with the fundus of the gallbladder, taking down adhesions and delineating anatomy, this decision appears to be warranted. As the surgeon delves deeper, however, (toward cystic duct and artery), a solid mass of inflammation makes it virtually impossible to discern the patients anatomy. In addition, the patient may develop a bile leak. At this point, the surgeon decides to switch to an open procedure, which under these circumstances is much safer for the patient.

In this situation, appending the -22 modifier to the open cholecystectomy code may be appropriate if the patients condition warrants more time and effort by the surgeon. The important thing to remember here is that the change from laparoscopic to open alone does not validate the use of modifier -22. If the switch had occurred shortly after the procedure began, modifier -22 would not be appropriate; conversely, had the surgeon opted for an open procedure at the start, modifier -22 might have been appropriate if significant time and effort was required to delineate the patients anatomy.

Attaching modifier -22 should depend on the kind of problems the surgeon runs into, Elliott says. I wouldnt say you should never use a -22, but there would have to be extenuating circumstances. Converting to gain better access or to facilitate removal of the gallbladder is commonplace, Elliott says, and therefore, modifier -22 shouldnt be used in those situations.

Because carriers have specific requirements that must be met before they will pay extra for claims with modifier
-22 attached, claims should document that the service provided was significantly greater than what is usually required for the procedure. The fee assigned for the open cholecystectomy is based on the average time it takes to perform the procedure. The procedure may take an additional 20 minutes on one occasion, but extra time does not warrant extra reimbursement. After all, when procedures take less time than average, physicians do not expect to get paid less than usual.

Additional Diagnosis Code Required

Regardless of whether the situation warrants the use of modifier -22 or not, an additional diagnosis code V64.4 (laparoscopic surgical procedure converted to open procedure) should be attached to indicate the switch. If modifier -22 is appended, using this secondary diagnosis code is critical, because it helps explain to the carrier why the extra reimbursement is being claimed. The switch from laparoscopic to open does not affect the primary diagnosis code (gallstones [e.g., 574.20, cholelithiasis; calculus of gallbladder without mention of cholecystitis] or inflammation of gallbladder [e.g., 575.0, acute cholecystitis], for example).
Tip: Diagnosis code V64.4 should never be used as a primary diagnosis.