General Surgery Coding Alert

Medicare requires you to bundle 'converted' scopes to open procedures

Most general surgery coders are familiar with coding guidelines that bundle diagnostic endoscopic procedures (such as thoracoscopy) to surgical scopes of the same type, but you can report multiple procedures if the diagnostic scope led to the decision to perform an open surgical procedure, or if the surgeon performs more than one surgical endoscopic procedure.
 
To ensure you're coding everything that your surgeon deserves payment for, follow these four tips.

1. True 'Diagnostic' Scope = Separate Payment

If the surgeon performs a diagnostic thoracoscopy (six codes, 32601-32606), and the results of the examination determine the need for an "open" surgical procedure, you may report the diagnostic thoracoscopy separately, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.

National Correct Coding Initiative (NCCI) guidelines state (in three separate locations) that if the surgeon performs an endoscopy for an initial diagnosis on the same day as the open procedure, you may report the endoscopy separately.

NCCI instructions indicate that you should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the open procedure "to indicate that the diagnostic endoscopy and the open surgical service are staged or planned procedures."

"For staged procedures, I include the word 'staged' as often as possible in the procedure description, diagnosis and clinical history so that the payer knows why I am using modifier -58," Barone says. "For instance, I'll describe the procedure as 'staged open pneumonectomy after a diagnostic thoracoscopy.' "

Example: The surgeon uses diagnostic thoracoscopy to examine a patient with a pain and breathing difficulty (32601, Thoracoscopy, diagnostic [separate procedure]; lungs and pleural space, without biopsy). The surgeon identifies and locates a foreign body in the pleural space, and removes the object via incision and thoracotomy (32150, Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit).

In this case, because the thoracoscopy led to the decision to perform the thoracotomy (an open surgical procedure), you should claim both procedures, using 32601 and 32150-58.

Caution: If the surgeon uses a diagnostic scope to assess the surgical field to establish anatomic landmarks, or to discern the extent of disease, you cannot report the diagnostic scope separately. Such "scout" scopes are bundled to the surgical procedure. Rather, the diagnostic scope must lead directly to the decision to perform surgery.

Extra coding tip: Do not report 32002 (Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]) in addition to thoracoscopy codes 32601-32606 and 32650-32665.

To perform thoracoscopy, the pleural space between the lung and chest wall must be large enough so that the surgeon can move the instruments around easily and visualize all areas of the thoracic cavity. 

The surgeon must create a pneumothorax (32002) to provide this space. Therefore, CMS considers the pneumothorax as an integral component of thoracoscopy and bundles 32002 to 32601-32606/32650-32665 in the NCCI.

2. Bundle Diagnostic Scopes to Surgical Scopes

When the surgeon performs a diagnostic thoracoscopy followed by a surgical thoracoscopy (16 codes, 32650-32665), you may report only the surgical thoracoscopy, regardless of whether the results of the diagnostic scope prompted the surgical scope.

CPT instructions clearly state, "Surgical thoracoscopy always includes diagnostic thoracoscopy" (emphasis added).
 
In addition, CPT designates diagnostic thoracoscopy codes 32601-32606 as "separate procedures," meaning that you may report such procedures only if they are "carried out independently or considered to be unrelated to or distinct from procedures/services provided at that time." NCCI reiterates these same guidelines.

Example: Consider once again the above example of the foreign-body removal from the pleural space. If, instead of thoracotomy, the surgeon removes the object via thoracoscopy (for example, 32653, Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit), you would not report the diagnostic thoracoscopy (32601) separately. Rather, report the surgical scope (32653) only, with no modifiers appended.

3. Report Multiple Surgical Scopes Separately

When the surgeon performs multiple surgical thora-coscopies at different sites during the same operative session, you may report each scope separately, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J.

Example: For a patient with repeated pneumothorax, the surgeon uses the thorascope to induce adhesion (32650 Thoracoscopy, surgical; with pleurodesis]).
 
At the same time, he performs a segmentectomy (32663, ... with lobectomy, total or segmental).

You should report 32663, followed by 32650. The payer may impose a multiple-procedure payment reduction on the second (and any subsequent) scope.
 
4. When Converting, Only Claim Open Procedures

If the surgeon must convert from an endoscopic (thoracoscopy) to an open(thoracotomy) procedure, you should only report the open procedure, Barone says.
NCCI guidelines specifically state, "When an endoscopic service is attempted and fails and another surgical service is necessary, only the successful service may be reported."

Example: Consider a final time the case in which the surgeon attempts to remove a foreign body in the pleural cavity. He begins by attempting to use the thorascope (32653) but, due to difficulties, he must abandon the scope and remove the foreign body via thoracotomy (32150).

In this case, NCCI guidelines dictate that you should report the "successful procedure" (that is, the thoracotomy) only.

Extra coding tip: Turn to modifier -22 (Unusual procedural services) for difficult thoracoscopy-to-thoracotomy conversions.

If the surgeon spends a long time attempting to complete a thoracoscopy before ultimately converting to an open approach, you may be able to access modifier -22 to account for the extra effort and boost reimbursement, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

"Often surgeons spend more time trying to perform the [endoscopic] procedure than it would usually take to perform the entire open procedure," Bucknam says. "If the surgeon decides he has to convert, he has the additional work of starting over. If the surgeon describes this process well, payers will often provide additional reimbursement for this additional time and work."

Warning: Don't report a "failed" endoscopic procedure in addition to an open procedure. Because the surgeon began with a thoracoscopy, you may be tempted to report 32653 with modifier -53 (Discontinued procedure) in addition to 32150, but this is incorrect. You should claim 32150 only.

"As long as the surgeon completes the service, you should bill the successful procedure only," said Deborah Berry, CPC, during her presentation on modifiers at the American Academy of Professional Coders' 2004 national conference in Atlanta.