General Surgery Coding Alert

CPT also adds new codes for APBI catheter, debridement

Revisions to integumentary system codes 10040-19499 in CPT 2005 mean you'll be able to report several procedures that previously had no codes - including, most notably, a long-awaited code for removal of mesh prosthetic.

Get ready now: Keep in mind that for 2005, neither Medicare payers nor practices billing Medicare payers are allowed the usual 90-day "grace period" to transition to the new codes. Beginning Jan. 1, 2005, you must use CPT 2005 exclusively for Medicare payers, according to CMS transmittal 95 (February 2004).

11008 Describes Mesh Removal, But Wait for CPT Instructions

With +11008 (Removal of prosthetic material or mesh, abdominal wall for necrotizing soft tissue infection [list separately in addition to code for primary procedure]), CPT finally includes a code you can use when the surgeon removes prosthetic mesh, but it's too soon to determine if 11008 is your magic bullet for all mesh removal cases.

"The problem lies with how CPT will define 'necrotizing,' " says M. Trayser Dunaway, a general surgeon in Camden, SC. "All infections are necrotizing to a degree, but most clinicians aren't going to label an infection necrotizing unless it is a rampant, overwhelming, 'flesh-eating' infection."

In other words, depending on CPT instructions and/or payer response, you may be able to apply 11008 only in limited circumstances, when the mesh has become severely and dangerously infected.

Surgeons often place mesh to strengthen hernia repairs, but if the mesh becomes infected, the surgeon must remove it, which can prove difficult and time-consuming.

Prior to 2005, CPT included no code to describe this service, leaving coders to guess whether they should turn to an unlisted-procedure code, apply modifier -22 (Unusual procedural services) to the primary surgery code to describe the additional work, or simply included the mesh removal as an unreimbursable component of the surgery.

"We just don't know yet if 11008 will solve the problem or only confuse the situation," Dunaway says.

This much is sure: Because removal of infected mesh always occurs during another, more extensive procedure, the AMA has designated 11008 as an add-on code. Therefore, you should only report 11008 in addition to another, primary procedure code.

APBI Catheter Placement? Now There's 19296-19297

Surgeons placing catheters for accelerated partial breast irradiation (APBI) no longer have to scratch their heads and wonder how they will be paid.

Two new codes cover the procedure: 19296 (Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy) and add-on code +19297 (Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy [list separately in addition to code for primary procedure]).

Report 19297 for same-day placement: Codes 19296 and 19297 describe identical procedures, although 19297 occurs on the same day as the mastectomy (with which you should list it), while 19296 occurs at a later date (and requires no primary procedure code to accompany it).

Proxima Therapeutics' MammoSite radiation therapy system involves inserting a balloon catheter into the breast. APBI targets part of the breast after a lumpectomy over a five-to-six-day period instead of the weeks that older techniques require. Many carriers issued Local Coverage Determinations for APBI last summer, but until now there was no way to bill for the catheter placement.

A third code, 19298 (Placement of radiotherapy afterloading brachytherapy catheters [multiple tube and button type] into the breast for interstitial radioelement application following [at the time of or subsequent to] partial mastectomy, includes imaging guidance), covers the insertion of radiotherapy afterloading brachytherapy catheters of the older multiple tube-and-button type. 

New data on partial breast irradiation spurred the introduction of 19296-19298, says Michael Steinberg, MD, who represented the American Society for Therapeutic Radiology and Oncology in the CPT Editorial Panel meetings. Before, "there was no reimbursement for the physical work of placing [the catheters]," he says.

Look to 19160/19162 for 'Partial' Mastectomy

CPT has revised the descriptors for 19160 (partial mastectomy) and 19162 (partial mastectomy with axillary lymphadenectomy). The new descriptors give examples of partial mastectomy as "lumpectomy, tylectomy, quadrantectomy or segmentectomy."

"Surgeons have long wanted to use the partial mastectomy codes to describe lumpectomies and other partial excisions," says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. "The addition of these examples to the CPT code descriptor now allows coders to use 19160 and 19162 even when the surgeon removes significantly less than a quarter of the breast tissue."

Proceed with caution: Bucknam does see a potential problem, however. "The new descriptors for 19160 and 19162 do leave some questions about the appropriate use of 19120 [Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions], which we have been using for lumpectomies. Coders will have difficulty defining the line between 19160/19162 and 19120 without a clarification from CPT."

Check Specific Codes for Perineum Debridement

If your surgeon performs deep debridement of the external genitalia, perineum and/or abdominal wall, you should no longer turn to 11043 (Debridement; skin, subcutaneous tissue, and muscle) but instead look to one of three new site-specific debridement codes: