Medicare Compliance & Reimbursement

Question: I heard that Medicare will not pay separately for the removal of a healthy appendix. Is this true? Why not?

Answer: Yes. Sometimes a surgeon will remove a healthy appendix simply because he already has the patient's abdomen open and removing the appendix eliminates a potential health problem down the road. Thus, appendectomies during the course of more extensive abdominal procedures are not totally unusual.

For example, the surgeon may remove a patient's appendix during bariatric surgery (for example, 43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Roux-en-Y gastroenterostomy). Unless the appendix appears abnormal (with scarring or inflammation, for example), you must consider the appendectomy incidental to the surgery, and you should not report that procedure separately.

To avoid paying for removal of healthy appendixes, many payers will expect you to provide proof (such as an op report) that an appendectomy your surgeon performed during the same session as another procedure was medically necessary.

When your physician performs a medically necessary appendectomy at the same time as another procedure, you'll turn to +44955 (Appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure] [List separately in addition to code for primary procedure]). A medically-necessary appendectomy must meet two requirements before you can report it:

1. Your surgeon clearly documented a problem with the appendix

2. Other procedures during the same session do not relate directly to the right colon.