General Surgery Coding Alert

Question: The patient starts with a laparoscopic procedure for cholecystectomy, but after one hour, the procedure needs to be converted to an open procedure for completion. This could also apply to appendectomy. How do you code the procedure(s), do you use the same ICD-9 code, and do you use a modifier?

James H. Risko, MD
Knox Surgical Specialists, Mount Vernon, OH

Answer: The procedure should be coded 47600 (cholecystectomy) with a -22 (unusual procedural services,) attached, says Cindy Parman, CPC, of Coding Strategies, Inc., a Dallas, GA-based consulting firm.

According to the General Coding Policies outlined in HCFAs National Correct Coding Initiative, which is increasingly in use by other private payers as well, when an endoscopic service is attempted and fails and another surgical service is necessary, only the successful service may be reported. An example is the attempted laparoscopic cholecystectomy converted to an open cholecystectomy.

According to Kathy Mueller, RN, CPC, CCS-P, a physician reimbursement specialist who currently consults with Allan L. Liefer, MD, FACS, a general surgeon in Chester, IL, if efforts to keep the procedure laparoscopic before the conversion to open took an extra 50 percent of the physicians time, a modifier -22 can be added to the open procedure.

Modifier -22 should be appended to the code to designate unusual procedural services. In the scenario outlined in the reader question, the extensive amount of time should reflect difficulty, and that (hopefully) is documented in the operative note.

Parman adds that an insurance claim that includes modifier -22 should be submitted to the payer with a copy of the operative note to verify the extensive nature of the services. The fee charged for this service would be increased due to the additional time, effort and skill required for the completion of the surgery.

The same ICD-9 code should be used in either case, because the same end result occurred and would include the reason for the cholecystectomy (gallstones, inflammation of the gall bladder, etc.).

But because the modifier -22 was added to the procedure, a secondary ICD-9 code, a V64.4, which is a laparoscopic procedure converted to open would need to be added to the claim as well to support modifier -22.

Appendectomies are different, Mueller says, citing a scenario where a patient complained of abdominal pain, and when the surgeons went in laparoscopically to investigate they found the appendix ruptured. But since the laparoscopic endoscopy was diagnostic in this case, it could be billed in addition to the surgical procedure.