General Surgery Coding Alert

CMS, along with the National Technical Information Service (NTIS), has released version 8.3 of the national Correct Coding Initiative (CCI) for the fourth quarter of calendar year 2002 (Oct. 1-Dec. 31). This latest CCI with nearly 55,000 code-pair revisions encompasses the largest number of changes since version 6.3. Unlike past CCI revisions, in which the greatest number of changes were concentrated on bundling anesthesia and E/M services to more extensive procedures, version 8.3 focuses on surgical and injection procedures, including many relevant to surgical practice.

The category defined as mutually exclusive by CCI (procedures not generally reported together due to the impossibility or improbability of performing them during the same session) contains few edits of interest for surgeons. Among them, open arteriovenous anastomosis by forearm vein transposition (36820) has been classified as mutually exclusive of a host of procedures, including 36800-36815, 36821-36822 and 36825-36861. In this case, 36820 is listed as a "category 2" code, i.e., it will not be recognized if reported with a second, mutually exclusive procedure. But 36820 has also been designated a category 1 code with anastomosis code 36819 and cannula insertion procedure 36823, i.e., if 36819 or 36823 and 36820 are mistakenly reported together, only the latter will recognized.

CCI also imposes new code-pair edits on several laparoscopy codes. For example, Surgical laparoscopy for ablation of one or more liver tumor[s]; radiofrequency (47370) has been designated a category 2 code mutually exclusive of cryosurgical laparoscopy (47371) and excision/destruction procedures 49200 and 49201. Code 47371 has also been designated a category 2 code with 49200 and 49201.

Following a similar pattern, CCI considers radio-frequency ablation 47380 exclusive of cryosurgical ablation 47381, and percutaneous radiofrequency ablation 47382 exclusive of 49200. And 49201 is designated exclusive of 47382.

With the exception of the 36820/36821 code pair, all of the above edits include a "1" status indicator, meaning the edit pairs can be circumvented if the procedures are performed at separate anatomic sites and if an appropriate modifier (e.g., modifier -59, Distinct procedural service) has been appended to the category 2 code.

CCI 8.3 contains no deletions in the mutually exclusive pair edits.

The familiar comprehensive/component edit pairs, in which a "lesser" service is bundled to or incidental to a more inclusive service, undergo significant revision in version 8.3. Specifically, as standards of care evolve, CCI continues to adapt by disallowing separate payment for injection or related services and (less frequently) imaging services (e.g., use of operating microscope, 69990) that routinely accompany many procedures.

Three codes in particular 36000* (Introduction of needle or intracatheter, vein), 36410* (Venipuncture, child over age 3 years or adult, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture) and 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]) are the object of so many new edits as to be nearly "universally" bundled and almost never available for separate payment if billed with another procedure. Code 36002 (Injection procedures [e.g., thrombin] for percutaneous treatment of extremity pseudoaneurysm]) undergoes similar, but less drastic revision and is now included in many codes in the 34001-36870 range.

Because of the sweeping nature of these changes, all surgical practices are encouraged to have an updated version of CCI (see "CCI 101" on page 84 for subscription information) or up-to-date billing software that automatically screens for CCI code-pair edits, and to pay special attention to claims for 36000, 36002, 36410 and 37202 to be sure that separate billing is not prohibited with other procedures provided. Note, however, that these edits generally include a 1 status indicator, thereby allowing for separate reimbursement for 36000, 36002, 36410 or 37202 under certain circumstances.

"The CCI edits do not preclude use of the modifiers if you perform and document a separately identifiable service on the same day as an injection, for instance," says Gregory J. Mulford, MD, medical director at Atlantic Rehabilitation Services and chairman of Rehabilitation Medicine at Morristown Memorial Hospital in New Jersey. In particular, he points to modifiers -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for injections performed with E/M services and -59 when injections are performed with other procedures at a different anatomic location.

Few other edits of interest for general surgeons appear in CCI 8.3. Among them, 35820 (Exploration for postoperative hemorrhage, thrombosis or infection; chest) has been bundled to ventricular access/removal codes 33979 and 33980. Exploration for postoperative hemorrhage, thrombosis or infection; extremity (35860) is now included in 35820.

Ablation code 47380, which also underwent revisions in the mutually exclusive category (above), now includes as bundled 44005 (Enterolysis), laparascopic enterolysis (44200), and 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]). Ablation procedure 47381 likewise bundles 49000.

Code 44205 (Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy) now includes 44204 (... colectomy, partial, with anastomosis).

None of the code-pair deletions in version 8.3 of CCI apply to surgical coding.