General Surgery Coding Alert

Heed ‘separate procedure’ direction.

Stumbling into one of the many adrenal-resection coding pitfalls could cost your general surgery practice plenty.

That’s why you need to follow our experts’ pointers to make sure you avoid bundling issues, capture legitimate additional charges, and get home by six.

Tip 1: Direct Code Choice by ‘Approach’

With advances in imaging technologies such as MRI, physicians are identifying more adrenal masses that indicate the need for surgery. “Adrenal glands are small, but open surgery is often difficult and requires a large excision due to the glands’ location deep in the retroperitoneum,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr.

Given those difficulties and the advent of less invasive alternatives, you shouldn’t be surprised to learn that the majority of adrenal surgeries today are laparoscopic.

Caution: Despite the preponderance of laparoscopic adrenalectomies, you can’t make an assumption about your surgeon’s approach. In fact, the first thing you need to find out from the op note is whether the procedure is open or laparoscopic. That distinction will lead you to one of the following primary codes:

• 60650, Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal
• 60540, Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure)

CPT^® typically distinguishes tissue removal procedures by surgical approach such as open, laparoscopic, core needle, etc., so that’s why you’ll find the 60650/60540 distinction for adrenal glands.

Surprise: But unlike surgeries involving other organs, CPT^® doesn’t differentiate between resection and biopsy for adrenal tissue. You’ll notice that both 60650 and 60540 describe an “adrenalectomy, partial or complete” OR “exploration of adrenal gland with or without biopsy.” That means you’ll choose one of these codes whether the surgeon simply “explores” the adrenal gland or removes the entire organ.

Tip 2: Look for Other Tissues

When you code an adrenalectomy, you might find additional tissue(s) documented in the op report that will change how you report the case.

For instance: If the surgeon finds and excises a retroperitoneal mass associated with the adrenal gland, you can alter your coding and collect appropriate pay. For an open procedure, that means changing your code selection from 60540 to 60545 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal [separate procedure]; with excision of adjacent retroperitoneal tumor). For a laparoscopic procedure, you might consider adding modifier 22 (Increased procedural service) to your 60650 claim, or reporting an unlisted code such as 60659 (Unlisted laparoscopy procedure, endocrine system) in addition to 60650 to describe the extra dissection and surgical work to remove the retroperitoneal mass.

Look for lymph: If the surgeon removes a lymph node or nodes in addition to an adrenal gland, you might be able to separately code the procedure using a code such as 38564 (Limited lymphadenectomy for staging [separate procedure]; retroperitoneal [aortic and/or splenic]) or 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling [biopsy], single or multiple), depending on the approach.

Cost: Missing this extra work, such as a 38570 lymph node dissection in addition to a 60650 lap adrenalectomy, could cost your practice. Although your payer will impose a multiple-procedure payment reduction on the second scope procedure, you don’t want to miss the additional pay you deserve.

Example: If your surgeon performs 60650 and 38570, expect full reimbursement for the procedure with the highest relative value units (RVUs). That’s 60650 in this example, which pays $1,238.88 (2017 Medicare Physician Fee Schedule [MPFS] national facility amount, conversion factor 35.8887). Additionally, most insurers will also pay 50 percent of the lesser service, or $261.63 (half of $523.26, the 2017 MPFS national facility amount for 38570).

Remember bilateral: If the surgeon removes or biopsies both adrenal glands, you’ll need to append modifier 50 (Bilateral procedure) to the code. Medicare and many other payers will pay 150 percent of the fee-schedule amount for bilateral procedures. That means getting paid $1656.97 by using modifier 50, instead of $1104.65 for a bilateral open adrenalectomy (60540) billed without the modifier (2017 MPFS national facility amount, conversion factor 35.8887).

“Some payers may not recognize modifier 50, and may want you to submit the procedure code twice using modifiers LT (Left side [used to identify procedures performed on the left side of the body]) and RT (Right side [used to identify procedures performed on the right side of the body]),” Joy says.

Tip 3: Beware Bundled Services

Sometimes you’ll find a surgical report that includes an adrenal gland and other tissue that you can’t code separately, notably, the kidneys.

“An adrenalectomy is included in all radical nephrectomies, whether performed open or laparoscopically,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York in Stony Brook.

You should never separately report an adrenalectomy with a procedure such as 50545 (Laparoscopy, surgical; radical nephrectomy [includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]), because the code definition clearly includes the adrenal gland removal.

But Medicare’s National Correct Coding Initiative (CCI) goes further and includes an adrenalectomy as part of a simple nephrectomy (which doesn’t include node dissection, Gerota’s fascia removal or lymphadenectomy), bundling the open and laparoscopic adrenalectomy codes with all nephrectomy codes.

Separate procedure: This CCI bundling conforms to CPT® rules for “separate procedure” codes such as 60540 and 60545. According to CPT^® instruction, “Codes designated as ‘separate procedures’ may not be additionally reported when the procedure/service is performed as an integral component of another procedure/service.”