Ob-Gyn Coding Alert

From the Ob-Gyn Coding Alert
Extra Supplement on Endoscopic Procedures

When the ob-gyn must convert a laparoscopic procedure into an open surgery because of intraoperative findings, use the right modifier to ensure your practice gets the reimbursement for the extra work involved in the operating room.

The current accepted rule of thumb when reporting a laparoscopy that becomes open maintains that you can bill for the open procedure, but not the initial laparoscopic portion. According to the most recent Correct Coding Initiative (CCI) edits, version 8.3, "when an endoscopic service is attempted and fails and another surgical service is necessary, only the successful service is reported." Generally, the successful service is the more invasive, CCI continues. Note that this is a published Medicare rule that may or may not be in place with non-Medicare payers.

Nonetheless, coders may still be confused about how to report the conversion from a laparoscopic approach to an open procedure, especially when the ob-gyn spends a large amount of time before he or she decides to convert. If coders are unaware of the guidelines, they may use inappropriate coding techniques to gain additional reimbursement, which may lead to claim denials and fraud allegations.

Use Modifier -22 With Special Circumstances

One strategy you might use when the physician converts from a laparoscopic procedure to open surgery would be to report only the open procedure appended with modifier -22 (Unusual procedural services), says Dee Mandley, RHIT, CCS, CCS-P, director of HIS and education for CURES, a coding and compliance consulting firm in Twinsburg, Ohio. But you should use this modifier only if the documentation indicates that the open procedure was significantly more difficult than usual. The fact that the ob-gyn converted the procedure is not enough. If the physician switched the approach shortly after beginning the procedure, modifier -22 would not be appropriate.

Philip Eskew Jr., MD, medical director of women and infants' services at St. Vincent's Hospital's Family Life Center in Indianapolis, agrees that modifier -22 may be the answer: "I favor using the -22 modifier when it becomes necessary to convert to an open procedure. First, it was not planned. Second, it is not my routine to perform a diagnostic laparoscopy before opening. And third, I would document extensively why I did it, what I saw that caused me to convert, how I did it, and how it benefited the patient."

Attaching this modifier should depend on the type of problems the surgeon runs into. You should use modifier -22 only when the physician feels that he expended a great deal of extra time and expertise. If the ob-gyn commonly converts from laparoscopic to open, you should not use modifier -22 because this conversion is "normal" and "routine" for the surgeon. "Routine use of the modifier is inappropriate, as this practice would suggest cases routinely have unusual circumstances," CCI states.

For example, an ob-gyn attempts to remove a large ovarian cyst laparoscopically. He tries for 10 minutes to mobilize the left ovary, but it is very dense and immobile, and he decides to convert to laparotomy. The surgeon finds that the cyst is densely adhered to the pelvic sidewall due to endometrial implants and discovers endometriosis in other parts of the pelvic area. He eventually mobilizes the ovary using blunt dissection to remove the endometrial implants and takes out the cyst.

The surgeon's findings of endometrial implants and endometriosis (617.x) led him to decide to change to an open procedure. In the process, the ob-gyn also removed the endometrial implants. Because of the additional work involved in first attempting to perform the procedure laparoscopically, you could use modifier -22.

Consequently, you should report the procedure as 58925-22 (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). Code 58925 covers the open procedure, and modifier -22 indicates the extra work involved with the unsuccessful laparoscopy. Code 49200 reflects the surgeon's work to remove the endometrial implants. When filing the claim, you should send in the operative report and a letter from the surgeon explaining the procedure's difficulties because modifier -22 almost always forces the carrier to review the claim.

Faced with the above scenario, some coders might be tempted to report a diagnostic laparoscopy (49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) as well, appended with modifier -52 (Reduced services), seeking reimbursement for the initial attempted procedure. Unfortunately, this probably will not work for Medicare because the ob-gyn did not plan a diagnostic laparoscopy in this case.

Although the surgery ultimately became a laparotomy and not a laparoscopy, bundling issues will likely remain in place. This essentially means that Medicare will bundle the laparoscopic portion of the procedure as the usual examination that is part of any procedure.

In addition, you would not report a failed laparoscopic ovarian cystectomy (58662, Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) because the surgeon did not appear to perform any substantive work on the cyst before switching to the open approach.

But Medicare rules do not apply to everyone, says Jan Rasmussen, CPC, president of the Eau Claire, Wis.-based Professional Coding Solutions and a former member of the AAPC advisory board. "The AMA generally advises that there is enough work in a failed laparoscopic procedure to bill the failed procedure with modifier -52 with the V64.4 code (Laparoscopic surgical procedure converted to open procedure) and then the open procedure." Similarly, some carriers will instruct providers to report a diagnostic laparoscopy and then the open procedure, Rasmussen notes, adding that you should contact your payers for their specific policies.

Although the coding guidelines for reporting surgeries when a laparoscopy is converted to an open procedure are fairly straightforward, some coders attempt to code and bill for both by appending modifier -53 (Discontinued procedure) to the laparoscopy code. Some coders claim they even receive reimbursement when using this reporting method, but this modifier is clearly inappropriate in this scenario and should not be used, coding experts say.

According to CPT, "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 life-threatening situations, such as uncontrollable bleeding, hypotension, neurologic impairment or cardiac arrest.

Based on this definition, you should not use modifier -53 if the surgeon successfully completes the service, even if he or she uses a different technique to complete the procedure. CPT developed the modifier to report a procedure that is completely discontinued with the patient sent either home or to the recovery room, not to report a procedure that is converted to another approach. Just because some carriers reimburse these modifier -53 claims even repeatedly does not make it correct coding.

Whenever you code for a laparoscopy turned open surgery regardless of whether you choose to report it with a modifier remember to adhere to the following requirements: