General Surgery Coding Alert

Question: During a cholecystectomy using the laparoscope, the surgeon documented spending 75 minutes lysing “very dense, adherent” adhesions using sharp dissection. Should we add 44180 to the cholecystectomy code for the services provided?

Texas Subscriber

Answer: No, you should not code 44180 (Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)) in addition to the code for the primary procedure, 47562 (Laparoscopy, surgical; cholecystectomy).

Here’s why: National Correct Coding Initiative (NCCI) bundles the codes with 44180 as a column 2 code for 47562 with a modifier indicator of “0,” meaning that you can never override the edit pair. Also, the words “separate procedure” in the 44180 code descriptor should tip you off that the service is bundled with a primary procedure at the same anatomic site. Lysing adhesions is an integral part of many abdominal surgeries.

However, when the work that’s required to provide a service is substantially greater than what’s typically required, that’s occasion to apply modifier 22 (Increased procedural services). You’ll want to be discerning and use this modifier sparingly, providing plenty of documentation.

In your example, the surgeon’s documentation includes details regarding increased time spent and that the service was significantly more difficult than usual, so it is appropriate to append modifier 22 to the 44180 code.

Payer policies: Many payers will have their own requirements for modifier 22. Medicare Part B payer Novitas Solutions, for example, states in its modifier 22 policy, “You may report modifier 22 when work to provide a service is substantially greater than typically required.”

Novitas Solutions adds, “Documentation must support the substantial additional work and the reason for the additional work, which may include:

• Increased intensity
• Time
• Technical difficulty of procedure
• Severity of patient’s condition
• Physical and mental effort required

Your documentation should provide our reviewers with a clinical picture of the patient; the procedures/ services performed and support the use of modifier 22. Depending on the documentation, we may or may not allow additional reimbursement” (Source: www. novitas-solutions.com/webcenter/portal/ MedicareJH/ pagebyid?contentId=00135206).