General Surgery Coding Alert

The 2001 CPT manual, which becomes effective Jan. 1, 2001, includes several new codes and code revisions that affect general surgeons. Topping the list of changes is a reorganization of breast biopsy codes that includes three new codes and changes to several others all of which could significantly alter how these procedures are billed.
In addition, CPT 2001 includes an example that supports use of modifier -62 (two surgeons) by both surgeons during arthrodesis co-surgery, as well as a new section for abdominal aortic aneurysm.

Coinciding with the release of CPT 2001, the Health Care Financing Administration (HCFAs) final rule (which contains the 2001 fee schedule) was published in the Nov. 1, 2000, Federal Register. In addition to boosting the relative value unit (RVU) conversion rate from $36.6137 per RVU in 2000 to $38.2581 per RVU in 2001, to a 4.4 percent increase, the fee schedule also includes coverage and reimbursement information about the new CPT codes outlined below.

Breast Biopsy

CPT 2001 now offers a broader range of codes to cover all of the different ways surgeons can perform a breast biopsy. The changes mean that there now are codes for needle and incisional biopsies of masses the surgeon can palpate, and other codes for stereotactic and other biopsies that use imaging guidance, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

The following three new CPT 2001 breast biopsy codes relate to imaging guidance:

19102 biopsy of breast; percutaneous, needle core, using imaging guidance (6.66 RVUs);

19103 biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance (13.28 RVUs); and

19295 image guided placement, metallic localization clip, percutaneous, during breast biopsy (list separately in addition to code for primary procedure) (2.62 RVUs).

The addition of 19102 is important because it distinguishes between needle core biopsies with and without imaging guidance, says M. Trayser Dunaway, MD, FACS, a general surgeon in Camden, S.C. This is a good code, and it should pay a bit more (than the 19100), Dunaway says, noting that performing a biopsy with imaging guidance takes considerably more time than a basic needle core biopsy (19100).

Code 19103 describes the surgeons use of an automatic device to project the needle into the lesion or mass. Code 19295 should be used if the surgeon uses a new technique involving implanting a clip that monitors lesions over time. As an add-on (or list separately in addition to) code, 19295 should not be billed on its own, and most likely would be used appropriately with 19102.

In conjunction with the introduction of the new codes, the following existing breast biopsy codes have been revised:

19100 biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure);

19101 biopsy of breast; open, incisional;

19120 excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions;

19125 excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion;

19126 excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (list separately in addition to code for primary procedure); and

88170 fine needle aspiration; superficial tissue (e.g., thyroid, breast, prostate).

The changes to 19100 and 19101 are directly related to the introduction of 19102. The addition of not using imaging guidance clearly distinguishes 19100 from 19102, which says precisely the opposite. Similarly, the introduction of the word percutaneous serves to highlight the differences between the needle core biopsy (19100) and incisional (19101) or excisional biopsies (19120), both of which now include the word open.

The introduction of 19102 also may put an end to anomalous coding instructions issued by some Medicare carriers to distinguish between palpable and nonpalpable lesions located using imaging guidance. Although nonpalpable lesions make up the large majority of stereotactic breast biopsies, many Medicare carriers cover stereotactic breast biopsy for palpable lesions in certain circumstances.

Nonpalpable lesions are more difficult to biopsy, however, so some carriers, such as Palmetto Government Benefits Administrators in South Carolina and Wisconsin Physician Service (WPS), in Wisconsin and Illinois, have issued guidelines instructing providers to distinguish between the two by using 19100 for palpable lesions and 19101 for nonpalpable lesions, even though 19101 describes an incisional not a needle core biopsy.

With the introduction of 19102 specifically for imaging guidance needle cores, and the revision of 19101 to include the word open, carriers are likely to drop the distinction between palpable and nonpalpable biopsies under stereotactic guidance and instruct providers to use 19102 in both situations, Callaway-Stradley says.

The word open also was added to codes 19125 and 19126, which are used for the excision of nonpalpable biopsies located by a technique called needle placement.

This procedure is performed when the surgeon cannot perform a stereotactic biopsy. Because excisions are by definition open procedures, this change amounts to little more than editing, as does the removal of the words with or without preparation of smears from fine needle aspiration code 88170.

Biopsy Section Revises Descriptors

Following the description of 19102, CPT 2001 notes 76095, 76360, 76393 and 76942 are associated radiology supervision and interpretation (S&I) codes. In CPT 2000, a similar note under 19100 included only 76095 and 76942.

The revisions to the wording of the radiology codes were probably made to make the descriptors conform more to medical practice and should not affect breast biopsy coding or billing.

Because imaging guidance of breast biopsies relies on radiological equipment, the following radiology codes from the 70000 section also may be used to bill for these procedures:

76095 stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation;

76096 mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation;

76360 computerized tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation; and

76942 ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

CPT 2001 also added the following new code for magnetic resonance imaging (MRI) guidance:

76393 magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection or placement of localization device), radiological supervision and interpretation.

Using Modifier -62 in Co-surgery Procedures

CPT now has a new guideline that states 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 modifier -62 to the single definitive procedure code. The guidelines goes on to add that if additional procedure(s) (including add-on procedure[s]) are performed during the same surgical session, separate code(s) may be reported by each co-surgeon, without modifier -62 appended. An example includes a vignette of an arthrodesis co-surgery using an anterior approach, in which a general surgeon is required to expose the spine and mobilize the great vessels.

General surgeons often have difficulty persuading co-surgeons (typically, an orthopedic or neurosurgeon) to bill for this procedure (22558, lumbar arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace) using a -62 modifier. Instead, some co-surgeons direct the general surgeon to use code 49010 (exploration, retroperitoneal area with or without biopsy[s] [separate procedure]). But July 1996 regulations in HCFAs national Correct Coding Initiative rejected the use of 49010 (or 49000, exploratory laparotomy and 32100, thoracotomy) for exposing the spine, and consider such use fraudulent.

The new CPT example states that the general surgeon who exposed the spine and moved the vessels should report 22558-62, and the co-surgeon also should report 22558-62, in addition to the appropriate codes for the diskectomy and fusion.

Naso- or Oro-gastric Intubation

Despite the introduction of a new CPT code, many carriers are unlikely to pay for naso- or oro-gastric intubation by a surgeon. This service is typically performed by a nurse, but sometimes the patients circumstances make the intubation more difficult and a physician has to be called in. That is why 43752 (naso- or oro-gastric tube placement, necessitating physicians skill) includes the phrase necessitating physicians skill.

CPT 2001 also instructs physicians to use 76000 (fluoroscopy, [separate procedure] up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) if fluoroscopy is used to guide the tube and ensure it doesnt enter the patients lungs.

But, CPT also states that 43752 is included in critical care (99291-99292) and should not be billed separately in those situations.

Because intubation is also considered an integral part of most procedures, 43752 should be coded only when no other procedure is performed (i.e., at bedside). Even so, most carriers likely will not pay for the service. In its 2001 fee schedule, HCFA did not associate any work RVUs with 43752 and says it deferred making a recommendation on the practice expense [RVUs]. In short, 43752 has no RVUs. The Final Rule states that We believe this service is bundled into evaluation and management services. In the fee schedule, 43752 has a B status indicator, which means HCFA considers it a bundled code, and therefore, payment for covered services is always bundled into payment for another service.

If the carrier does not cover 43752 and all the surgeon did was intubate the patient, an appropriate (low) level evaluation and management (E/M) code should be used.

Endovascular Graft Repair Coding

A new section in CPT 2001 contains 12 new codes (34800-34826) that describe placement of an endovascular graft for abdominal aortic aneurysm (AAA) repair under fluoroscopic guidance. These procedures include vascular access, all catheter manipulations, balloon angioplasty within the endovascular prosthesis (for full expansion of the endoprosthesis) and closure of the arteriotomy site, according to section guidelines preceding the codes.

The guidelines contain valuable information about when these codes may and may not be billed with other procedures, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. The following procedures are examples of such:

Fluoroscopic guidance during these procedures is coded separately using one of two new radiology supervision and interpretation codes 75952 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) or 75953 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm, radiological supervision and interpretation).

Code 75952 includes angiography of the aorta and its branches for diagnostic imaging prior to deployment of the endovascular device (including all routine components of modular devices), fluoroscopic guidance in the delivery of the endovascular components, and intraprocedural arterial angiography (e.g., confirm position, detect endoleak, evaluate runoff). Code 75953 includes the analagous services for placement of additional extension prostheses (not for routine components of modular devices)

Extensive repair or replacement of an artery should be additionally reported (e.g., 35226 or 35286).

Other interventional procedures performed at the time of endovascular abdominal aortic aneurysm repair should be additionally reported (e.g., aortography before deployment of endoprosthesis, renal transluminal angioplasty, arterial embolization, intravascular ultrasound, balloon angioplasty of native artery[s] outside the graft [e.g., aortic or iliac] before deployment of endoprosthesis).

The new AAA codes are:

34800 endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis (31.96 RVUs);

34802 endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (one docking limb) (35.27 RVUs);

34804 endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis (35.27 RVUs);

34808 endovascular placement of iliac artery occlusion device (list separately in addition to code for primary procedure) (6.07 RVUs);

34812 open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral (9.94 RVUs);

34813 placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (list separately in addition to code for primary procedure) (7.06 RVUs);

34820 open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (14.35 RVUs);

34825 placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; initial vessel (19.09 RVUs);

34826 placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; each additional vessel (list separately in addition to code for primary procedure) (6.07 RVUs);

34830 open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis (49.74 RVUs);

34831 open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis (53.77 RVUs); and

34832 open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bifemoral prosthesis (53.77 RVUs).

Additional Codes and Revisions to CPT 2001

The following is a list of more new codes and revisions made:

Laparoscopic liver procedures. Beginning in Jan. 2001, if a surgeon performs a laparoscopic liver biopsy, only 47399 (unlisted procedure, liver) can be used to code for the procedure. CPT 2001 has added 47379 (unlisted laparoscopic procedure, liver), making it easier to bill for any procedure (liver biopsies, for example) performed laparoscopically.

Esophageal ultrasound. Codes 43231 (esophagoscopy, rigid or flexible, with endoscopic ultrasound examination; 6.17 RVUs) and 43232 (esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]; 7.17 RVUs) should be used when surgeons perform esophageal ultrasound, often on cancer patients to determine if the esophagus is resectable or not. The imaging provided by the ultrasound enables the surgeon to see tissue planes between the esophagus and surrounding tissue. This allows the surgeon to see if the tumor has penetrated other planes or is still contained in the esophagus. Code 43232 involves taking a biopsy if something is found.

Intestinal stents and endoscopic ultrasound. Intestinal stents usually are performed on cancer patients as a palliative alternative to bypassing or resecting the intestine(s). An example is a stent that opens stricture of the duodenum caused by pancreatic cancer. Nine new codes describe procedures associated with intestinal stent placement. These are:

44370 small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) (6.15 RVUs);

44379 small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) (10.04 RVUs);

44383 ileoscopy, through stoma, with transendo- scopic stent placement (includes predilation) (3.43 RVUs);

44397 colonoscopy through stoma; with transendoscopic stent placement (includes predilation) (6.43 RVUs);

45327 proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) (2.41 RVUs);

45341 sigmoidoscopy, flexible; with endoscopic ultrasound examination (5.36 RVUs);

45342 sigmoidoscopy, flexible, with transendo-scopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) (6.18 RVUs);

45345 sigmoidoscopy, flexible, with transendo- scopic stent placement (includes predilation) (4.14 RVUs); and

45387 colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) (8.39 RVUs).

Laparoscopy codes revised. The word surgical has been removed from 49320 (laparoscopy, abdomen, peritoneum and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), and three subsequent laparoscopy codes have been edited accordingly. These are:

49321 laparoscopy, surgical; with biopsy (single or multiple);

49322 laparoscopy, surgical; with aspiration of cavity or cyst (e.g., ovarian cyst) (single or multiple);

49323 laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity.

According to the HCFAs national Physician Fee Schedule, multiple endoscopy guidelines apply to this four-code family, and now, 49320 is the familys base code.

Nonobstetrical vaginal hematoma. This problem is usually not treated on its own, and as a result, when surgeons performed I&D on a vaginal hematoma, the only way to bill for the service was to add modifier -22 (unusual procedural services) to the other procedure performed. Now CPT has added code 57023 (incision and drainage of vaginal hematoma; non-obstetrical [e.g., post-trauma, spontaneous bleeding]) (4.30 RVUs, 10-day global period). The key word to note in the code descriptor is non-obstetrical.

Percutaneous AV fistula thrombectomies. Code 36870 (thrombectomy, percutaneous, arteriovenous fistula, autogenous or non-autogenous graft [includes mechanical thrombus extraction and intra-graft thrombolysis) (non-facility), (36.23 RVUs; facility, 8.07 RVUs) has been added, and 36831-36833 have been revised to include the word open. In other words, percutaneous thrombectomies, performed by catheter or AngioJet, now have their own code, which shouldnt be confused with open AV fistula thrombectomies or revisions.

Note: For more on AngioJet, see You be the Coder, on page 100.

Blood sample collection by venous device. Sometimes surgeons take blood specimens for the lab during surgery. CPT 2001 has added 36540 (collection of blood specimen from a partially or completely implantable venous access device) for this service. Code 36540 has a B status indicator, which means HCFA considers it bundled to any other service and does not intend to pay for it.

Harvest of upper extremity artery. Vascular surgeons should note the introduction of code 35600 (7.47 RVUs), which is to be used when a segment of artery is harvested for a coronary artery bypass procedure.

Intestinal transplantation. CPT has introduced four new codes for transplant procedures involving the small intestine. This procedure is performed only at a few hospitals in the United States, but is becoming more widely available. The new codes are:

44132 donor enterectomy, open, with preparation and maintenance of allograft; from cadaver donor;

44133 donor enterectomy, open, with preparation and maintenance of allograft; partial, from living donor;

44135 intestinal allotransplantation; from cadaver donor; and

44136 intestinal allotransplantation; from living donor.

Note: HCFAs fee schedule lists these procedures with an N status indicator, which means the procedures are considered noncovered services by Medicare.