General Surgery Coding Alert

Question: I find two codes in CPT for repair of ileoanal pouch fistula/sinus that differ only according to the approach the surgeon uses. How can I differentiate between the two?

Minnesota Subscriber

Answer: Check the procedure notes carefully. If the surgeon states that during surgical preparation he prepped the abdomen and perineum, that's a tip-off for a combined approach as described by 46712 (Repair of ileoanal pouch fistula/sinus [e.g., perineal or vaginal], pouch advancement; combined transperineal and trans-abdominal approach). Be sure that you pay attention, however, to where the surgeon then places the incisions. Sometimes, the surgeon will prepare both areas but may revert to a single approach (46710, - transperineal approach), depending on how the exploration unfolds.

The distinction matters: If the operative report leaves you any doubts as to which code you should select, ask the surgeon for guidance. In a facility setting, the "double" approach (46712) pays more than 52 relative value units (RVUs) instead of about 25.15 RVUs (a difference of about $1,000) for 46710. So a mistake could be costly.

Make the documentation clear: If you have trouble determining the approach, not only should you ask the surgeon to clarify for you, but you should also ask the surgeon to amend the documentation. If the operative note is unclear to you (who works with the physician all of the time), it will also probably be unclear to any auditor or medical reviewer checking the documentation.