Urology Coding Alert

Look for situations that will allow modifier 22 and boost your pay.

Lysis of adhesions might seem like a simple procedure, but sometimes the encounter – and, therefore, the coding – can get more complicated than expected.

Starting point: Adhesions are bands of fibrous scar tissue that can form after surgery or because of infection. They potentially can lead to a wide range of complications because they connect organs and tissues that are normally separated.

Some adhesions (such as many that form on an infant’s penis after circumcision) are mild and break on their own, others need to be addressed by a urologist. Mild adhesions can be broken in the office, but others require more involved treatment.

The next time you see lysis of adhesions as part of a procedure, keep the following real-world examples and tips from coding experts in mind to increase claims success.

Example 1: Performing Lysis of Adhesions With Circumcision

Scenario: The urologist performs lysis of adhesions for a patient who had a previous incomplete circumcision. He wants to report both 54162 (Lysis or excision of penile post-circumcision adhesions) for the adhesions and 54163 (Repair incomplete circumcision) for the redundant foreskin.

Code it: In this situation, you should only bill code 54163. Payers consider the lysis of adhesions before a circumcision or repeat circumcision to be included in (and bundled into) the work of 54163. Surgically speaking, the lysis of adhesions is part of the circumcision because it prepares the operative site for the circumcision. Appending a modifier such as 59 (Distinct procedural service) in an attempt to receive separate payment for the lysis is unbundling thesurgical procedure itself and will not pass muster with a payer.

Scenario 2: Coding for Removal of a Skin Bridge

Scenario: The urologist documents a circumcision with removal of a skin bridge. You aren’t sure how to report the skin bridge removal.

Code it: Ignore the term “skin bridge,” because it is basically a fancy name for an adhesion on the glans penis.

If your urologist detached adhesions between the glans penis and foreskin prior to circumcision, report 54161 (Circumcision surgical excision other than clamp device or dorsal slit; older than 28 days of age).

Example 2: Determining Whether Modifier 22 Applies

Scenario: During a laparoscopic partial nephrectomy, the urologist completes laparoscopic removal of adhesions between the patient’s abdominal wall and omentum.

 Code it: As with the circumcision codes mentioned previously, the work of a nephrectomy includes the work associated with lysis of adhesions. Therefore, in most situations you will only report the laparoscopic partial nephrectomy with 50543 (Laparoscopy, surgical; partial nephrectomy).

Exception: If the lysis of adhesions took a substantial amount of time and effort – and the urologist’s documentation supports that claim, you may consider appending modifier 22 (Increased procedural services) to potentially earn extra reimbursement, according to Dorine Marshall, CPC, a biller with OSU Physicians in Tulsa, Ok.

Remember, however, that experts say you should not report modifier 22 on a regular basis. Every surgeon has cases that are more difficult than average and ones that are easier. Just because one case is more extensive or time-consuming than another does not automatically mean you should append modifier 22.

To report modifier 22, you should have supporting documentation in the operative report that details the physician’s extensive time and work effort.

“Quantifying the additional time and specifying the increased effort in the documentation is crucial for reimbursement success,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. Look for terms in the chart such as “very difficult,” “unusually difficult,” or something similar to help bolster your case for modifier 22.

Take note: Payers will likely ask for more information when a claim includes modifier 22, so be sure your physician’s operative report substantiates the claim. When responding to a payer’s request related to modifier 22, include a cover letter that compares the additional time and effort to the average time and effort the procedure usually takes. The details that made the procedure difficult provide a better level of understanding to the insurance reviewer who may not be aware of the typical efforts involved in the procedure.

Our experts also recommend that you include an estimate of what you expect to be paid for the extra work involved in the procedure. Including a dollar amount doesn’t guarantee what the payer will reimburse that amount, but assigning a figure to it gives the payer a better idea of the work the urologist did and could help your reimbursement be more appropriate.

Bottom line: Coding for a procedure that includes lysis of adhesions can mean you are due additional reimbursement, but only in two circumstances:

• When the lysis of adhesions is extensive rather than routine, and
• When the adhesions the urologist addresses are in a different anatomic site from the main procedure(s).

Example 3: Paying Attention to Different Sites

Scenario: The urologist performs a laparoscopic lysis of extensive pelvic and ovarian adhesions and then performs an open limited lysis of abdominal adhesions and a transabdominal open radical nephrectomy.

Code it: Determining the site where the urologist lysed adhesions is an important factor in determining which procedure code set to use. For example, if he completed adhesiolysis of the bowel, you would report 44005 (Enterolysis [freeing of intestinal adhesions] [separate procedure]) or 44180 (Laparoscopic, surgical enterolysis [freeing of intestinal adhesions] [separate procedure]) if appropriate, depending on the approach. If the urologist lysed pelvic adhesions, submit 58660 (Laparoscopy, surgical, with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]) or 58740 (Lysis of adhesions [salpingolysis, ovariolysis]) if appropriate, depending on the exact location of the adhesions. Although CCI bundles most abdominal and pelvic surgical procedure with most lysis of adhesion codes, there are unusual clinical circumstances when the urologist uses a different approach at a different surgical site. In these cases, if clinically reported and documented, you can bill both procedures using the appropriate CPT^® lysis codes.

Example: Appropriate coding would include 50230 for the open transabdominal radical nephrectomy and lysis of limited adhesions and 58660 for the laparoscopic lysis of extensive pelvic adhesions.

One more caveat: Always check the CCI edits before billing adhesiolysis on the same date as any other procedure. You will find edit pairs that restrict reporting most abdominal or pelvic codes with a separate code for lysis of adhesions. These edit pairs typically show a modifier indicator of “0,” meaning that you cannot unbundle these codes using a modifier such as modifier 59 (Distinct procedural service).