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General Surgery Coding Alert

Thoracic-Related Procedures Offer Legitimate Opportunity for Additional Payment

Published on Tue Jan 01, 2002

Surgeons who perform thoracic-related procedures may not be obtaining all the  reimbursement they are ethically entitled to for bronchoscopies performed during the same session as thoracic procedures, thoracotomy performed for diskectomy in conjunction with another specialist, transthoracic mediastinal procedures, thoracic lymphadenectomies and other situations like these.
 
Correctly documenting and coding these procedures may yield additional payment; in addition, coding guidelines outlined here can prevent general surgeons from being underpaid for their services during an operative session.

Bronchoscopy

A surgeon can perform bronchoscopy on a patient for diagnostic purposes, recommending thoracic surgery in cases where bronchoscopy identifies a problem. The surgeon may report the diagnostic bronchoscopy separately using 31622 (bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]), says Marcella Bucknam, CPC, a general surgery coding and reimbursement specialist and a coding instructor at Clarkson College in Omaha, Neb. It should not be billed if the bronchoscopy is performed for another reason, she says, pointing to instructions in Correct Coding Manual Version 7.3 (the latest version of the manual that compiles all changes to the Correct Coding Initiative [CCI]) that specifically discuss bronchoscopies performed during the same session as a thoracic procedure.
 
Chapter Six of CCI states that "if an endoscopy is performed for purposes of an initial diagnosis on the same day as the open procedure, the endoscopy is separately reported." However, CCI adds: "Assuming that a diagnostic bronchoscopy has already been performed for diagnosis and biopsy and the surgeon is simply evaluating for anatomic assessment for sleeve or more complex resection, the bronchoscopy would not be separately reported. Essentially, this 'scout' endoscopy represents a part of the assessment of the surgical field to establish anatomical landmarks, extent of disease, etc.  If an endoscopic procedure is done as part of an open procedure, it is not separately reported." Furthermore, when "the procedure is performed for diagnostic purposes immediately prior to a more definitive procedure, the -58 modifier [staged or related procedure or service by the same physician during the postoperative period] may be utilized to indicate that these procedures are staged or planned services."
 
Chapter Five of CCI elaborates on this scenario, citing the example of a bronchoscopy that reveals the patient has a lobar foreign body obstruction. A thoracotomy is performed, after an attempt to remove the foreign body bronchoscopically failed. "In this example, if the endoscopic effort was unsuccessful and a thoracotomy is planned, the diagnostic bronchoscopy could be separately coded in addition to the thoracotomy. The -58 modifier may be used to indicate that the diagnostic bronchoscopy and the thoracotomy are staged or planned procedures." If the surgeon "decides to repeat the bronchoscopy after induction of general anesthesia to confirm the surgical approach to the foreign body, billing a service for this confirmatory bronchoscopy is inappropriate." If bronchoscopy is performed after surgery for purposes of evaluation, it also should not be separately billed, Bucknam says.

Thoracotomy, Diskectomy and Modifier -62

When performing a diskectomy or other spinal surgery via an anterior approach, an orthopedic surgeon or neurosurgeon may require the services of a general surgeon to provide access. These doctors may recommend that the general surgeon bill for his or her role in the session by reporting a thoracotomy code from the 32100 series (thoracotomy, major; with exploration and biopsy). Such billing is inappropriate and may be considered fraudulent by the carrier, who bundles the approach with the procedure performed. For example, if the orthopedist performs a thoracic diskectomy, 63077 (diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, single interspace) includes the thoracotomy. To bill this session correctly, both surgeons should report 63077 with modifier -62 (two surgeons) appended.
 
Medicare carriers are instructed to pay modifier -62 claims at 125 percent of the normal rate, with each surgeon receiving half of the fee. General surgery billing staff are advised to contact their counterparts at the orthopedic or neurosurgical practice to coordinate billing, Bucknam says. If the orthopedist bills the procedure without modifier -62, it may be difficult and time-consuming for the general surgeon to obtain payment.
 
A similar situation occurs when the general surgeon's services are required for arthrodesis performed via an anterior approach. It is incorrect for the general surgeon to bill 49010 (exploration, retroperitoneal area with or without biopsy[s][separate procedure]) for the laparotomy in such cases. Instead, CPT 2002 includes the following instructions under its "Spine" subsection: "When two surgeons work together as primary surgeons performing distinct part[s] of a single reportable procedure, each surgeon should report his/her distinct operative work by appending the modifier -62 to the single definitive procedure code."
 
These instructions apply to thoracic as well as abdominal approaches, Bucknam says, noting that the only difference is that the thoracic procedure that should not be separately billed (32100) pays at a higher rate than the non-reportable laparotomy (49010).

Thoracotomy and Mediastinotomy

Surgeons may need to access the mediastinal space for a variety of reasons. The mediastinum is a retrosternal area that may be explored via a cervical or transthoracic approach. There are two ways to execute a transthoracic approach:  thoracotomy or median sternotomy. The 32000 series of thoracotomy codes should not be used in such cases, Bucknam says. Instead, coders should use 39010 (mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy). "When looking for a suitable thoracotomy code for this service, people might not think to look at this code, because they are looking for a thoracotomy, whereas this code is elsewhere in the CPT manual," Bucknam says.  Furthermore, she notes, "if the surgeon performed the mediastinotomy using a thoracic approach, he or she may refer to the procedure as a thoracotomy, or an exploration between the lungs, confusing the coder even more."  Meanwhile, if the surgeon performs two distinct scope procedures thoracoscopy and mediastinoscopy each may be reported separately, using the appropriate thoracoscopy code and 39400 (mediastinoscopy, with or without biopsy), Bucknam says.

Lymph Node Excision

Surgeons who perform thoracic procedures can lose reimbursement that they are ethically entitled to if they do not bill for additional services that may be reported separately. If the surgeon performs a pneumonectomy to remove a cancerous lung, notes M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C., the lymph nodes are likely to be removed as well. "You're removing lymph nodes in addition to the primary tissue that you're after, much like a mastectomy that involves axillary lymph node dissection," Dunaway says. Although codes like 19162 (mastectomy partial; with axillary lymphadenectomy) include lymph node excisions, lymphadenectomy performed in conjunction with a thoracic procedure may be reported separately. Some general surgery practices may not be aware that 38746 (thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes [list separately in addition to code for primary procedure]) may be reported in these situations.

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