Ob-Gyn Coding Alert

When a laparoscopic gynecological surgery is converted to an open procedure due to intraoperative findings, the accepted rule of thumb is that coders can bill for the open, but not the initial laparoscopic procedure. But using the right modifier may help your practice get paid for the extra work in the operating room.

 

 

According to the national Correct Coding Initiative (CCI) edits, version 7.1 (April-June 2001), when a second procedure is performed because the initial approach was unsuccessful in accomplishing the required service, "only the CPT code for one of the services, generally the more invasive service, should be reported." 

Many Medicare carriers also have local medical review policies (LMRPs) that address this issue and describe the two procedures (open and laparoscopic) as mutually exclusive. For example, Wisconsin Physician Service, the Medicare Part B carrier in Wisconsin, Illinois and Michigan, states that one reason procedures may be deemed mutually exclusive is if they "represent two methods of performing the same service."

In spite of these guidelines, some surgeons may be confused about how to code the conversion from a laparoscopic to an open procedure, particularly if a lot of time was spent before the decision to convert. If coders are unaware of the guidelines, they may sometimes use inappropriate coding strategies to gain additional reimbursement, but this can lead to denials or even fraud charges.

 

In the gynecological surgical setting, there are a few scenarios where laparoscopies are converted to open procedures. For instance, an excision of an ovarian cyst that proves to be more complicated than originally thought, or extensive adhesions that must be taken down via an open incision to accomplish the original procedure. 

Although the coding guidelines for this situation are straightforward -- only the open procedure should be billed -- some coders incorrectly code and bill for both the laparoscopic and open procedures by appending modifier -53 (discontinued procedure) to the laparoscopic procedure. While some coders report that their carrier pays such claims, this modifier in this scenario is clearly inappropriate and should not be used, coding experts say. 

The CPT descriptor for modifier -53 states, "Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued." Such circumstances include potentially life-threatening situations, such as uncontrollable bleeding, hypotension, neurologic impairment or cardiac arrest.

"Given CPT's explanation, modifier -53 should not be used if the surgeon successfully completes the service, even if another technique is used to complete the service," says Melanie Witt, RN, CPC, MA, an independent coding consultant and ob/gyn coding expert based in Fredericksburg, Va. "It was developed to report a procedure that was completely discontinued with the patient sent either home or to the recovery room, not to report a procedure that was converted to another approach. The fact that some carriers may be paying such claims, even if they do so repeatedly, does not make it correct coding."

 

 

Another strategy used by coders to gain extra reimbursement for their surgeons who convert a laparoscopic procedure to an open is to bill only for the open procedure, as per the guidelines quoted above, but with modifier -22 (unusual procedural services) attached.

Modifier -22, however, should be used only if the documentation indicates that the open procedure was significantly more difficult than usual. The fact that the procedure was converted from laparoscopic to open isn't enough. "The important thing to remember here," Witt says, "is that the change from laparoscopic to open alone does not validate the use of modifier -22." If the switch had occurred shortly after the procedure began, modifier-22 would not be appropriate.

Attaching modifier -22 should depend on the kind of problems the surgeon runs into, and -22 should be used only in cases when the surgeon feels that much extra time and expertise were expended. If conversion from laparoscopic to open is a common occurrence for the physician, modifier -22 is not a good option because this conversion is "normal" and "routine" for the surgeon. 

The following surgical case study illustrates a typical scenario and the proper coding sequence. 

In this case, the ovarian cyst was densely adhered to the pelvic wall due to endometrial implants, and endometriosis was present in other parts of the pelvic area, which led to the decision to change to an open procedure. In the process, the surgeon also removed endometrial implants. Given the additional work involved in first attempting to perform the procedure laparoscopically, modifier -22 may be justified. 

Witt says the ovarian cyst removal is coded 58925 (ovarian cystectomy, unilateral or bilateral), and 49200-51 (excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas, -multiple procedures) can also be reported for the removal of the endometrial implants. "The only question is whether the payer will recognize a converted procedure as deserving of more money," she adds. "Some coders might advocate billing for a diagnostic laparoscopy (49320-52, laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure], -reduced services), but my experience says this will probably not work, since a diagnostic laparoscopy was not planned in this case." Although ultimately the final surgery was a laparotomy and not a laparoscopy, the bundling issues are likely to remain the same -- that is, the laparoscopic part of the surgery is bundled as the usual "look see" that is part of any procedure. Witt adds that coders should not bill for a failed laparoscopic ovarian cystectomy (58662) because it does not appear that any substantive work was done on the cyst before the surgeon switched to the open approach to remove the cyst. 

Witt prefers a more viable alternative -- one that is more likely to ensure appropriate reimbursement. "I would add modifier -22 to the 58925 code to cover the extra work of trying to free up the ovary and send in the operative report and a letter from the surgeon explaining the difficulties," she says. This additional information is needed because modifier -22 will almost always force the claim to paper and require a carrier review.

 

 

In this case, the initial diagnosis code --and the reason for the initial laparoscopy -- was an unspecified ovarian cyst (620.2). Regardless of whether the situation warrants the use of modifier -22 or not, an additional diagnosis code -- V64.4 (laparoscopic surgical procedure converted to open procedure) -- should be linked to the ovarian cystectomy procedure code as well to indicate the switch. If modifier -22 is appended, this secondary diagnosis code is critical because it helps explain to the carrier why the extra reimbursement is being claimed. 

An additional diagnosis of 617.1 (endometriosis of the ovary) and 617.0 (endometriosis of uterus) would be linked to 49200 because this condition was diagnosed after converting to the open procedure and applies only to the removal of the endometrial implants.