General Surgery Coding Alert

Question: During bariatric surgery (43846) on a patient, the surgeon removed the patient's appendix. Can I report the appendectomy separately? New Jersey Subscriber Answer: Whether you can report the appendectomy separately depends on whether the surgeon's documentation shows medical necessity for removing the appendix. The surgeon needs to document that the appendix appeared abnormal and needed to be removed -- for example, because of scarring or inflammation. Surgeons often remove the appendix during bariatric surgery (as in this example, 43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Roux-en-Y gastroenterostomy). If the documentation supports that the surgeon had to remove the appendix because of evidence of inflammation or scarring, you may separately report the appendectomy. You should report +44955 (Appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure][List separately in addition to code for primary procedure]) in addition to the primary procedure performed. Bad news: If the physician's documentation does not show that the appendix was abnormal in some way -- in other words, if there was no medical necessity for removing the appendix -- then the removal is incidental to the surgery, and you should not report the appendectomy separately. Tip: Check the pathology report. Sometimes the path report will show inflammatory changes that the surgeon did not document in his note, which can support the medical necessity of the service, even if the op note doesn-t.