General Surgery Coding Alert

In some situations, a general surgeon may receive additional reimbursement for a laparoscopic cholecystectomy (lap chole). For example:

If significant additional work or time is required to lyse adhesions, repair a complication or convert the procedure from laparoscopic to open, modifier -22 (unusual procedural services) can be appended to the appropriate code and additional payment claimed; or

If the surgeon performs a cholangiogram with no radiologist present and provides the supervision and interpretation (S&I).

Additionally, by carefully reviewing the surgeons procedure notes, coders may uncover additional payment opportunities. For example, cholangiograms are frequently performed in conjunction with cholecystectomies (both laparoscopic and open), but occasionally the former procedure is not listed at the top of the operative report.

To optimize reimbursement in these situations, surgeons and their coders must ensure that documentation is both accurate and complete. Coders must also be aware of several coding guidelines and bundling edits that may apply.

A lap chole involves removal of the gallbladder using a laparoscope, and may be performed with or without cholangiography. The surgeon may also explore the common bile duct for gallstones at the same time. CPT 2001 includes the following lap chole procedures:

47562 laparoscopy, surgical; cholecystectomy;
47563 ... with cholangiography; and
47564 ... with exploration of common duct.

These codes which correspond to similar open procedures that follow in the CPT manual are arranged sequentially (i.e., 47563 includes 47562 plus cholangiography, and 47564 includes 47563 plus exploration of common duct). This is reflected in the relative value units assigned to each procedure: 47562, 18.17; 47563 19.59; 47564, 23.59. Therefore, these codes should never be billed together.

Tip 1: Read the Entire Operative Report

Cholangiography is often (but not always) performed when a gallbladder is removed to help the surgeon better determine the patients anatomy and to check for gallstones in the common bile duct, says Tray Dunaway, MD, FACS, a general surgeon and evaluation and management coding author in Camden, S.C. Some surgeons routinely include cholangiography (many surgeons have been trained to do so), whereas others may perform the service only for specific indications, such as an elevated liver function study, an ultrasound that shows an enlarged common bile duct or because the patient has a history of gallstone pancreatitis.

Because cholangiography is routinely performed in conjunction with a lap chole, some surgeons forget to mention cholangiography at the top of the operative report, says Elaine Elliott, CPC, an independent general surgery coding specialist in Stuart, Fla. If you read the top of the operative report, it may list laparoscopic cholecystectomy only, but the procedure notes in the operative report clearly state that a cholangiogram was performed, Elliott says. Thats why it is important to read the body of the operative note. I code from the record, never by what doctors write at the beginning. They may inadvertently add things they didnt do or leave out things they did.

Tip 2: Use Modifier -22 for Significant Additional Time

Occasionally a lap chole requires significant additional effort and time than routinely necessary. For example, the surgeon may:

perform extensive lysis of adhesions;

have to repair a bowel injury or deal with another complication; or

abandon the laparoscopic approach and perform an open procedure.

In all three situations, no additional codes may be billed. In some cases, however, surgeons can bill for significant extra work and time by appending modifier -22 to the appropriate procedure code.

For example, if the surgeon must perform extensive lysis of adhesions, 44200 (laparoscopy, surgical; enterolysis [freeing of intestinal adhesion] [separate procedure]) cannot be billed in addition to 47562 because the codes are bundled in the national Correct Coding Initiative (just as 44005, the code for open lysis of adhesions, is bundled to 47600, the open cholecystectomy code). The edit includes a 0 indicator, meaning that no override is possible using modifier -59 (distinct procedural service).

If the time spent lysing the adhesions is significant (i.e., 25 percent or more of the total time of the operative session), the appropriate lap chole code should be billed with modifier -22 attached.

Even more time may be required if the surgeon notices a perforation of the small intestine while adhesion lysis is being performed. The surgeon may spend 45 minutes repairing the perforation but cannot bill the procedure because, according to HCFA guidelines, physicians may not bill separately for complications that arise during an operative session.

Note: If the patient is brought back to the operating room for repair of the complication, modifier -78 (return to the operating room for a related procedure during the postoperative period) should be attached to the appropriate procedure code.

Again, modifier -22 should be appended to indicate that significant additional work and time were required to perform the procedure. The perforated bowel is not an error, says Terry Fletcher, BS, CPC, CCS-P, a coding and reimbursement specialist in Laguna Niguel, Calif. Rather, it should be viewed as an unfortunate side effect of lysing adhesions. Because a hole was inadvertently left in the bowel, the procedure becomes more complicated and takes longer to complete. You may appropriately bill the extra time using modifier -22.

Note: If the surgeon must repair a bowel injured by another physician, the procedure should be billed 44602 (suture of small intestine [enterorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture; single perforation), 44603 (. . .multiple perforations) or 44604 (suture of large intestine [colorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture [single or multiple perforations]; without colostomy), depending on the situation.

Converting Lap Chole to an Open Procedure

Sometimes a lap chole must be converted to an open procedure due to intraoperative findings, such as inflammation or extremely extensive adhesions.

When this occurs, HCFA coding guidelines clearly state that only the open procedure should be billed. According to the national Correct Coding Manual:

An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service; those procedures are considered sequential procedures. Only the CPT code for one of the services, generally the more invasive service, should be reported. An example of this situation is a failed laparoscopic cholecystectomy, followed by an open cholecystectomy at the same session. Only the code for the successful procedure, in this case the open cholecystectomy, should be reported. [emphasis added]

For example, the general surgeon begins a lap chole on a 68-year-old male with gallbladder disease. The laparoscope reveals that the area containing the gallbladder is severely inflamed and purulent. In addition, gangrenous changes and initial dissection result in perforations and consequent bile spillage. As a result, the surgeon converts to an open procedure.

In this situation, only 47605 (cholecystecomy; with cholangiography) should be billed. Although some surgeons try to bill both services by appending modifier -53 (discontinued procedure) to the lap chole with cholangiogram (47563, or 47562 if no cholangiogram was performed), this is incorrect because 47605 and 47563 describe different ways of performing the same service.

Modifier -53 should not be used if the surgeon successfully completes the cholecystectomy, even if another technique is used, Elliott says. As long as you continue on and successfully complete the service, you bill that service only.

Note: Although some carriers may be paying these claims with modifier -53 appended, such billing is nonetheless incorrect. At the very least, if the surgeons practice is audited, the payer may request a refund.

Nor is appending modifier -22 to the open procedure appropriate in the above scenario, Elliott warns. She notes that the surgeon opted to convert to an open procedure shortly after beginning the lap chole. Just because a procedure was converted from laparoscopic to open does not automatically justify the use of modifier -22, she explains. Converting to gain better access or to facilitate removal of the gallbladder is commonplace and, therefore, modifier -22 shouldnt be used.

In cases where the surgeon spends considerable time trying to perform the procedure laparoscopically before converting to open, however, modifier -22 may be appended to the open procedure (either 47600, cholecystectomy, or 47605).

For example, the surgeon attempts to remove an inflamed gallbladder laparoscopically. The surgeon initially works on the fundus of the gallbladder lysing adhesions and delineating anatomy and the approach appears to be correct. As the surgeon moves deeper (toward the cystic duct and artery), however, the patients anatomy becomes indiscernible due to a solid mass of inflammation. In addition, the patient develops a bile leak. The surgeon, increasingly concerned about proceeding under laparoscopic guidance only, converts to an open approach.

In this situation, appending modifier -22 to the open cholecystectomy code may be appropriate because the patients condition required more time and effort.

Guidelines for Billing With Modifier -22

Because of overutilization, modifier -22 has become a red flag for audit, and physicians must abide by stringent documentation and compliance guidelines when using it.

Because carriers dictate specific requirements for modifier -22, such claims should include a separate paragraph that describes the additional work involved, notes the additional time spent and explains (briefly, in simple terms) why the additional work was necessary. The average duration of the procedure should be contrasted with the time spent during the session.

Spending an extra 20 or 30 minutes is probably not enough, Elliott says, because fees are based on the average time it takes to perform the procedure.

In the case of a lap chole converted to an open procedure, an additional diagnosis code V64.4 (laparoscopic surgical procedure converted to open procedure) should be included to indicate that the switch occurred, according to the ICD-9-CM Coding Handbook. When modifier -22 is attached to the open cholecystectomy to note additional effort and time, this V code helps explain to the carrier why the additional payment is being claimed.

Note: The lap-to-open conversion does not affect the primary diagnosis code, and V64.4 should be used only as a secondary diagnosis.

Tip 3: Bill S&I If a Radiologist Isnt Present

When a cholangiogram is performed in conjunction with a lap chole and no radiologist is present, the surgeon will interpret the images on the fluoroscope to guide the procedure. For example, the surgeon may determine that the cholangiogram is normal after finding a normal anatomy with free flow of contrast into the duodenum and no filling defects in the common duct.

In this instance, the surgeons interpretation of the cholangiogram is separately payable as long as a separate radiology report is filed. Code 74300 (cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation) can be billed with modifier -26 (professional component) appended.

In many instances, however, the surgeons billing for S&I may not be that straightforward. Hospital policy usually dictates that anything sent back to the radiology department must generate a report signed by a hospital radiologist, even if S&I was already performed by the surgeon. Furthermore, carriers in some states may only pay for physician S&I performed by a certified radiologist.

HCFA policy, meanwhile, states that only one physician may be paid for performing radiological S&I. The same policy also states that the interpretation that ultimately guides the further treatment of the patient (i.e., the surgeons) should be paid, although this can be a delicate issue between surgeons and radiologists.