General Surgery Coding Alert

Answer: According to the national Correct Coding Initiative (CCI), a laparoscopic procedure converted to an open cannot be billed twice. Consequently, you cant bill for both procedures, say Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

Depending on the amount of time the surgeon spent on the laparoscopic cholecystectomy before deciding to switch to an open procedure, he or she can attach modifier -22 (unusual procedural services) to the open procedure (47600, cholecystectomy; 47605, with cholangiography). When submitting claims using modifier -22, the surgeon must provide full documentation to indicate why the procedure should be reimbursed at a higher rate. In the case of the laparoscopic cholecystectomy converted to an open, the extra time and effort should be indicated in a separate note. If the decision to switch to the open procedure was made soon after the procedure began, modifier -22 should not be included.

For example, if the surgeon completes 75 percent of the laparoscopic procedure and finds that he or she cannot get the gall bladder out, a separate letter should accompany the operative report to explain the extent of the laparoscopy and that it was converted to an open procedure just to remove the gall bladder.

Although this might appear to be an appropriate situation for attaching modifier -53 (discontinued procedure) to the laparoscopy code, Medicare specifically rules it out because the two procedures are different methods of accomplishing the same thing; in this case, a cholecystectomy. For example, Xact Medicare Services, the Medicare carrier in Pennsylvania, states, In the instance where a closed procedure, 56341, is attempted and the provider must resort to an open procedure, 47605, Xact Medicare Services will only consider payment for the major procedure of 47605. Only the most major procedure code, in this case the open procedure code, should be submitted for payment consideration.

According to Medicare, reporting both a laparoscopic and an open surgical approach to accomplish the same clinical outcome represents duplicity of efforts and overlapping of services.