General Surgery Coding Alert

Earn an extra $1,000 by coding the correct approach

Adding a single -extra- procedure during a variety of gastrointestinal surgeries can make a huge difference in your reimbursement dollars. When examining op notes, here are four examples of gastro surgeries that you should pay special attention to.

1. Watch for Pouch With Rectum Removal

If you find yourself reaching for new-for-2006 code 45395 (Laparoscopy,  surgical; proctectomy, complete, combined abdominoperineal, with colostomy), research a bit further to be sure you shouldn't assign 45397 (... proctectomy, combined abdominoperineal pull-through procedure [e.g., colo-anal anastomosis], with creation of colonic reservoir [e.g., J-pouch], with diverting enterostomy, when performed) for pouch creation instead. Code 45395 pays 47.83 relative value units (RVUs) in a facility setting, while 45397 reimburses 51.96 RVUs--a difference of about $150,  on average.

Tip: The surgeon may not explicitly state that he created a pouch, but he might list the types of staplers he used, and in which order, says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C. This could be a tip-off to you that he performed something more than lap removal of the rectum.

For instance: A laparoscopic surgeon may use a GIA stapler to make the pouch and an end-to-end anastomosing stapler to attach it. If you see documentation of this type, you might be looking at a 45397 claim instead of 45395.

Take the time to ask: If you think the documentation is unclear, don't hesitate to ask the surgeon exactly what he did. You don't want to give up reimbursement dollars, but neither should you report procedures that the documentation cannot support.

2. Approach Makes All the Difference

Pay attention to whether your surgeon repairs an ileoanal pouch fistula via the transperineal approach (46710, Repair of ileoanal pouch fistula/sinus [e.g., perineal or vaginal], pouch advancement; transperineal approach) or a combined transperineal-transabdominal approach (46712, -combined transperineal and transabdominal approach). The -double- approach pays 52.74 RVUs instead of just 25.15 RVUs in the facility setting (a difference of about $1,000).

-During the description of the prep, if the surgeon states the -abdomen- was prepped, along with the perineum, that's a tip-off of where incisions may be placed- [meaning a combined approach], Dunaway says. -Then during the operation, pay attention to where the incisions actually occur. Sometimes, the surgeon will prep both areas but may use different incisions depending on the information that becomes available during exploration.-

3. Sigmoid Resection Adds to Proctopexy

The addition of sigmoid resection 45402 (Laparoscopy, surgical; proctopexy [for prolapse], with sigmoid resection) with laparoscopic proctopexy (45400) can mean a more than $350 difference in reimbursement (37.86 RVUs for 45402 vs. 27.93 RVUs for 45400), so you don't want to misstep when reporting these procedures.

Read the entire op note: Usually, the medical record should state specifically that the surgeon removed the sigmoid colon, Dunaway says. Often, however, the surgeon may fail to list all relevant procedures in the -summary- portion of the op note, so you should read the entire report for evidence of sigmoid resection.

-Colo-rectal procedures can be complex and confusing, but asking your surgeon to explain the fundamentals of anatomy and the types of surgery with simple sketches can allow you to recognize the procedures and code more accurately,- Dunaway says.

New codes expand your billing options: Like 45395 and 45397, 45400 and 45402--along with 45499 (Unlisted laparoscopy procedure, rectum)--are new to CPT for 2006. These codes mostly parallel the existing codes for open procedures, Dunaway says. For instance, previous codes for proctectomy include 45110-45123, but none of these codes specified a laparoscopic approach, as 45395 and 45397 do.

-As people get more advanced with the laparoscopic skills, we-re doing more operations this way, instead of just gall bladders,- Dunaway says. -It's always good to have specific codes. That way, we don't have to guess if we-re going to get paid on something.-

Laparoscopic Splenic Take-Down Earns a Code

CPT 2006 also brings you a new add-on code for laparoscopic take-down of the splenic flexure. You should apply +44213 (Laparoscopy, surgical, mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]) only with codes 44204-44208, according to CPT guidelines.

The -open- equivalent of 44213 is +44139 (Mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]).

When applied properly, 44213 will reimburse 5.16 RVUs in the facility setting, or about $185.


4. Look for Replacement With Removal

If your surgeon only revises or removes a gastric port (as part of a gastric restrictive procedure), you-ll bill 43886 (Gastric restrictive procedure, open; revision of subcutaneous port component only) or 43887 (... removal of subcutaneous port component only) and receive about $275, on average, in a facility setting.

But if the physician removes and replaces the gastric port, you can report 43888 (... removal and replacement of subcutaneous port component only), says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif. Code 43888 pays over $100 more than 43886 and 43887. 

Bottom line: During gastric restrictive procedures, be sure to look for evidence that the surgeon replaced the port component following removal.

Get all the facts: For more on gastric restrictive procedures, see -Bariatric Surgery Code Overhaul- on page 1 of the January 2006 General Surgery Coding Alert.