Medical Necessity Required to Correctly Bill Appendectomy Add-on Code
Published on Sat Apr 01, 2000
General surgeons may face difficulties getting reimbursed when they perform an appendectomy (44955) at the same time as another unrelated procedure. But they can bill for the appendectomy as a primary procedure as long as there is a documented problem with the appendix and the other procedure doesnt relate directly to the right colon.
Finding appendicitis in a patient during the course of another procedure is not a common occurrence. More frequently, a patient may have a bowel obstruction and appendicitisin fact, the appendicitis may be the cause of the bowel obstructionbut if the obstruction requires a right colectomy (44140, colectomy, partial; with anastomosis), the appendectomy cannot be billed because the appendix is simply an extension of the cecum at the bottom of the right colon and is removed along with the rest of the resected colon.
Insurance carriers, including Medicare also will not reimburse the removal of a healthy appendix. Surgeons often perform appendectomies (particularly on younger patients) during the course of more extensive abdominal procedures. Although taking out an appendix because it is there is not as popular as it was in the past, many surgeons still remove a healthy appendix simply because they have already opened the patient and removing the appendix eliminates a potential subsequent health problem.
To avoid paying for removal of healthy appendixes, many carriers now want to see proof (i.e., the operative report) that an appendectomy performed during the same session as another procedure was medically necessary, which means many first claims routinely are denied.
In the past, some doctors billed carriers for removing an appendix in the course of a right colectomy, whereas others took out the appendix routinely when performing abdominal surgery, whether it was medically necessary or not, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. She adds that most carriers will reimburse appendectomies if they are truly distinct procedures and are medically necessary.
Separate Diagnosis Required
The correct CPT code in these situations is 44955 (appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure][list separately in addition to code for primary procedure]). The key words in 44955s descriptor are indicated purpose, which means the appendectomy must be medically necessary (i.e., a diagnosis or sign or symptom). If the surgeon doesnt have a specific diagnosis before opening the patient, then signs or symptoms should be used. If the appendix returns from the pathology lab showing disease, that information also should be provided to the carrier, says Karen Evans, RN, CPC, an independent coding and reimbursement specialist in Mount Vernon, Wash.
If a patient has a gallbladder or ovarian problem, for example, and the surgeon finds appendicitis [...]
