Urology Coding Alert

Modifier knowledge ends confusion

When the urologist starts a procedure laparoscopically and converts to an open surgery due to complications, make sure you consult individual carriers about whether you can report both the laparoscopy and the open procedure or whether you're limited to just one, as you are with Medicare.

Because laparoscopy is minimally invasive, it's emerging as a popular option for procedures such as nephrectomies and ureteroneocystostomies. Complications such as altered anatomy or poor visibility due to fibrosis or scarring, however, can make completing a laparoscopic procedure impossible. In such situations, the urologist is forced to complete the procedure as open. And that's when a challenging surgical situation then becomes a challenging coding situation.

Report the Open Procedure for Medicare

When one approach to a procedure fails and the surgeon must change to a second approach, "these procedures are considered 'sequential procedures,' " according to the National Correct Coding Policy Manual for Part B Medicare Carriers, version 10.3. The manual also states, "Only the CPT Code for one of the services, generally the more invasive service, should be reported."

The bottom line: Based on this Medicare policy, when a urologist converts a procedure from laparoscopic to open, you should only report the open procedure code.

Document Additional Surgical Time

One of the biggest problems coders face when they find themselves having to code for a lap-to-open procedure is "attempting to ensure the surgeon gets paid for the additional time within the limitations of proper coding," says Dan Rogers, administrator for Gulf South Urology and instructor at Healthcare Administrative Services in Biloxi, Miss.

Append modifier 22: By adding modifier 22 (Unusual procedural services) to the open procedure code, coders can account for the additional time the urologist spends attempting the procedure laparoscopically before having to convert to open. To add modifier 22, the operative report must show that the urologist performed work that was above and beyond the time and work normally required for the procedure.

Rosemary Russell, CPC, of Maine Urology Associates PA in Bangor, agrees and does exactly that. "Along with the claim form, I attach the operative report and a letter explaining the situation and the amount of extra work involved," she says.

Providing additional detailed documentation can help the coder get the most reimbursement possible. Be specific in the letter and explain the exact length of time the procedures takes. You can also indicate how much additional compensation the doctor should receive for the extra time spent on the procedure. According to coding experts, you should usually ask for at least 50 percent more.

Don't Forget the Diagnosis Code

When reporting a procedure that started laparoscopically and ended up open, be sure to use V64.41 (Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis code. Code V64.41 was added Oct. 1, 2003. The primary diagnosis code you report should be the reason that surgery was necessary.

Coding example: The urologist diagnoses a patient with end-stage hydronephrosis and decides to perform a hand-assisted laparoscopic nephrectomy. Because of excessive scar tissue, she has difficulty with the dissection and converts to an open simple nephrectomy. In this situation, report only 50220 (Nephrectomy, including partial ureterectomy, any open approach ...) for Medicare. If the surgeon thinks extra time was involved because of the laparoscopic procedure, and this added significantly to the overall time of the procedure, be sure to append modifier 22 to the code. You shouldn't report 50546 (Laparoscopy, surgical; nephrectomy) for the failed laparoscopic procedure.
 
Report 591 (Hydronephrosis) as the primary diagnosis code and V64.41 (Laparoscopic surgical procedure converted to open procedure) as the secondary diagnosis.

Private Carriers May Allow Alternative Coding

Some commercial carriers will pay for both the laparoscopic and open procedures. You would add either modifier 52 (Reduced services) or modifier 53 (Discontinued procedure) to the code for the laparoscopy in this case.

Coding example: For commercial carriers, the above clinical scenario may be coded as follows:
 

50546 (a few carriers may require modifier 59 [Distinct procedural service] to break the bundle with 50220)
 

50220-52, or -53 (either modifier indicating a reduced charge for the incomplete procedure).

Regulations vary from state to state and carrier to carrier, so be sure to check with your individual payers to see what their policies are regarding specific laparoscopic and open procedures.

Treat Diagnostic Laparoscopy Differently

If the laparoscopic procedure becomes solely for diagnostic purposes rather than to perform a surgery, don't use the same codes as you would for a converted procedure.

Coding example: The urologist performs a "diagnostic laparoscopy" to view a patient's kidney. Then, based on this diagnostic procedure and his findings that a laparoscopic procedure may not be suitable for the patient, he decides to perform an open nephrectomy. Report both 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic ...) and 50220 (Nephrectomy, including partial ureterectomy, any open approach ...).

Note: Because 49320 and 50220 are not bundled, most carriers will pay on both procedures. Check with your payers, however, to determine how they prefer to be billed.

You should also check with your carrier to see if adding modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the diagnostic laparoscopy is appropriate. Modifier 58 is not necessary for Medicare because the procedures are not bundled, but some carriers will require the modifier to indicate that this procedure was part of a staged procedure.