General Surgery Coding Alert

"Question: Our surgeon placed mesh with a zipper on an ICU patients abdomen. Subsequently, the physician performed abdominal washouts by reopening the abdomen through the zippered mesh. The service is performed daily at the patients bedside. How do we code this?

New Mexico Subscriber

Answer: Although the surgeon is irrigating the patients abdomen, the procedure described cannot be reported using codes 49080 or 49081 (peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial/subsequent). These codes involve the insertion of a needle, which was not done in this instance, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C.

Instead, the surgeon has placed a zippered mesh over the patients wound to facilitate repeated access to the abdomen for irrigations. To perform the irrigation, all the surgeon has to do is remove any dressing and open the zipper.

No code specifically addresses this situation, and therefore coders are left with 49002 (reopening of recent laparotomy; 17.85 RVUs), Callaway says. Laparotomies are typically reopened to control bleeding or contain infection, which usually involves making a new incision. Because in this case the surgeon unzips the mesh instead, modifier -52 (reduced services) should be appended to 49002 to indicate that the procedure was completed, but that the usual time and effort required were reduced.

Unless the wound is being irrigated for postoperative infections, each subsequent treatment should be billed separately as 49002-52-58. Modifier -58 (staged or related procedure) indicates that the irrigations were preplanned and are not part of 49002s 90-day global surgical package.

If the surgeon is treating a Medicare patient as a result of a postoperative complication, any irrigations performed during the 90-day global period are not separately payable. Modifier -78 (return to the operating room for a related procedure during the postoperative period) does not apply because the irrigations are performed in the intensive care unit (ICU), not in the operating room.

Some private payers may reimburse irrigations performed to treat postoperative infections. Depending on the payer, modifier -79 (unrelated procedure or service by the same physician during the postoperative period) may be required.

Note: For purposes other than postoperative complications, modifier -58 should always be used for subsequent lavages."