General Surgery Coding Alert

Question: Our surgeon performed an exploratory laparoscopy followed by an open cholecystectomy. I know that a diagnostic endoscopic procedure is included in a surgical endoscopic procedure, but does the same logic hold when the surgeon performs an open procedure?

Arizona Subscriber

Answer: If the surgeon performs either a laparoscopic or open surgical procedure subsequent to visualizing the area laparoscopically, you should include the diagnostic scope in the surgical procedure.

National Correct Coding Initiative (CCI) guidelines address this issue specifically: "An open cholecystectomy [47600] includes an examination of the abdomen through the abdominal wall incision. If this examination is performed laparoscopically, it is not separately reportable as CPT code 49320 [Laparoscopy, abdomen, peritoneum and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)]."

This logic applies in all cases when visualization precedes a surgical service. For instance, CCI guidelines explain, "Exposure and exploration of the surgical field is integral to an operative procedure and is not separately reportable. For example, an exploratory laparotomy [49000, Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)] is not separately reportable with an intra-abdominal procedure."

An important exception: Although CCI guidelines state, "A scout endoscopy to assess anatomic landmarks and extent of disease is not separately reportable with an open procedure," you may still report an endoscopic procedure separately if the endoscopic procedure prompts the surgical service.

In other words: If the surgeon already knows that he is going to perform surgery prior to a diagnostic scope, you may not report the diagnostic scope separately. But if the results of the diagnostic scope lead to the surgery, you may report the diagnostic scope separately by appending modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

CCI says, "The medical record must document the medical reasonableness and necessity for the diagnostic endoscopy. A scout endoscopy to assess anatomic landmarks and extent of disease is not separately reportable with an open procedure."