General Surgery Coding Alert

Cholecystectomy and/or appendectomy may count as separate procedures

Medicare has recently approved coverage for several types of previously uncovered bariatric surgery -- which means now is also the perfect time to brush up on your coding for these same procedures.

Here are the facts you need when reporting Roux-en-Y gastric bypass (43644-43645 and 43846-43847) and biliopancreatic diversion with duodenal switch (43845).

Roux-en-Y Won't Involve Gastrectomy

You can usually identify a Roux-en-Y procedure by the inclusion of the term -Roux-en-Y- in the operative report. This is the most common type of bariatric procedure surgeons now perform, says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis.

CPT includes two codes to describe -open- Roux-en-Y procedures:

- 43846 -- Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy

- 43847 -- - with small intestine reconstruction to limit absorption.
 
Code 43846 involves partitioning off a small section of the stomach (usually with staples) and dividing the small intestines. One portion of the small bowel is attached to the new stomach pouch, while the other (distal) portion of the bowel creates a -bypass- before rejoining the main portion of the small intestine, says Giselle G. Hamad, MD, FACS, assistant professor of surgery at the University of Pittsburgh. This restricts food intake and limits absorption.

Measurements matter: Code 43847 involves a more extensive rerouting of the small intestine (longer than 150-cm limb) to limit absorption further.

Although the surgeon resects the stomach, she does not remove any portion of it (gastrectomy) during 43846-43847. This is one way to differentiate these procedures from biliopancreatic diversion and biliopancreatic diversion with duodenal switch.
 
For Laparoscopic Procedures, Turn to 43644-43645

If the surgeon performs a Roux-en-Y bypass using the endoscope rather than using an open incision from the breastbone to the navel, you should turn to 43644 (Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less]) and 43645 (... with gastric bypass and small intestine reconstruction to limit absorption). These codes are identical to 43846 and 43847, except that they describe a laparoscopic approach.

Remember: You should never report the open and laparoscopic codes for the same procedure, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. If the surgeon converts a laparoscopic procedure to an open procedure, you should report the open procedure code only.

Biliopancreatic Diversion Includes Gastrectomy

You can identify the other newly covered bariatric procedure, biliopancreatic diversion with duodenal switch, because it involves gastrectomy (removal of a portion of the stomach) while preserving the pylorus and a short (2- to 4-cm) section of the duodenum, Rasmussen says. During Roux-en-Y procedures as described above, the surgeon completely bypasses the duodenum.

The appropriate code to describe biliopancreatic diversion with duodenal switch is 43845 (Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy [50 to 100 cm common channel] to limit absorption [biliopancreatic diversion with duodenal switch]).

The -switch- is essential: Biliopancreatic diversion with duodenal switch (DS) differs from simple biliopancreatic diversion (BPD), which is not a covered procedure for Medicare. Specifically, whereas the BPD involves an anastomosis (connection) between the stomach and the intestine, the DS involves an anastomosis between the duodenum and the intestine. More specifically, the DS maintains the presence of the pylorus, Rasmussen says.

If the op note is unclear, ask: Don't hesitate to consult with the surgeon if the documentation is unclear as to the nature of the surgery.

Don't Forget Separately Reportable Procedures

Surgeons often remove the appendix during bariatric surgery. You may report removal of the appendix separately using 44950 (Appendectomy) -- as long as medical necessity supports the procedure, Bucknam says.

Surgeons may remove the appendix as a preventive measure during bariatric surgery, but unless the appendix appears abnormal (with scarring and/or old inflammatory changes, for example), the removal is incidental, and you should not report 44950 separately.

Cholecystectomy follows similar guidelines: The same rules apply if the surgeon performs cholecystectomy -- which is also common during bariatric surgery. If the patient has cholelithiasis (gallstones) or cholecystitis (an inflamed gallbladder), for instance, you may legitimately report a separate cholecystectomy (47600), Bucknam says.

There are options: -You can bill for these procedures [44950 and 47600] if the physician describes conditions other than just appendicitis or cholecystitis/cholelithiasis,- Bucknam says.

-The physician may feel that the appendix looks enlarged, for example, even though the path report indicates there was nothing wrong,- Bucknam says. -And the gallbladder may be perceived as likely containing stones or the patient may have a history of right upper-quadrant pain, and this can be used to support the cholecystectomy even if the path doesn't come back with either acute or chronic changes. I have frequently seen this in coding bariatric surgery, and it does support the service.-