Code for Success When a Damaged Liver Needs Transplantation

By Shelly Bauguss, CPC, CGSC, CANPC, CGIC
St. Patrick’s Day became a custom in America in 1737, the first year that St. Patrick’s Day was publically celebrated in Boston. Today, people celebrate the day watching parades, wearing green clothes, and drinking beer.
Drinking beer or any alcoholic beverage in moderation is acceptable to most, but for others it is an addiction that, over time, can result in severe liver disease, most notably cirrhosis. Even for people who stop drinking alcohol, the effects are still evident in the body many years later.
Alcoholic cirrhosis is the most serious type of alcohol-induced liver disease. Cirrhosis is the replacement of normal liver tissue with scar tissue. According to the American Liver Foundation, www.liverfoundation.org, between 10 and 20 percent of heavy drinkers develop cirrhosis, usually after 10 or more years of drinking. The damage from cirrhosis is not reversible, and it is a life-threatening disease. The risk is particularly high for people who drink heavily and have another chronic liver disease, such as viral hepatitis C.
Liver transplantation is a common treatment for patients with alcoholic liver disease diagnoses in North America and Europe. The criterion for selecting a patient for liver transplantation with alcoholic cirrhosis is the patient must abstain from alcohol for six months. This has been referred to as the six month rule, and is used to predict future abstinence. An optimistic view about the salutary effects of transplantation on alcoholic relapse came from Thomas Starzl, who coined the aphorism, “liver transplantation was the ultimate sobering experience.”
All prospective liver recipients have the same consultation process and multi-disciplinary team conferences regardless of the patient’s diagnosis. As a transplant coder, the initial patient consultation is the first coding assignment. After the patient is placed on the transplant list with the United Network for Organ Sharing (UNOS), the search and the wait begins to find an appropriate donor organ for the recipient.

The Procurement Process

The organ placement process is outlined on the UNOS Web site (www.unos.org) as a complex organ matching process for potential recipients based on ranking, policy criteria, and organ offers. Calls are made in succession to multiple recipients transplant centers to expedite the placement process. When the organ is accepted for a recipient, the donor is taken to the operating room (OR) for organ harvest.
The procedure begins with donor brain death declaration, which is noted in the chart along with consent from an appropriate family member. The Ingenix Coders’ Desk Reference for Procedures 2009 outlines the procurement process with code 47133 Donor hepatectomy (including cold preservation), from cadaver donor as:

The physician performs a donor hepatectomy by removing the liver from a cadaver donor for transplantation into another recipient. The physician accesses the liver, which is mobilized from its attachments. The blood supply and bile ducts to the liver are dissected free and isolated. The liver is removed with its attached blood vessels and bile ducts and perfused with a cold preservation solution and removed from the operative field. The liver is preserved for transplantation into the recipient. The organ remains under refrigeration, specially packed in a sealable container with some preserving solution and kept on ice in a suitable carrier.

This code includes the graft, harvesting, and the cold preservation. When billing for the procurement, most guidelines state that documentation must include what type of organ preservation solution was used, e.g. custodial histidine-tryptophan-ketoglutarate (HTK). After the organ is procured, it is sent to the recipient’s surgical facility for the transplant.

Transplantation Process

The recipient’s transplantation process begins after the organ is accepted from the transplant center. The patient is brought to the OR and all standard practices of prepping, draping, and placing lines are performed.
The liver graft is brought to the operating room and the backbench procedures begin. The CPT^® manual has six standard backbench codes for this portion of the transplantation process. These codes are:
47140 Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)
47141  Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV)
47142  Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)
47143  Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split
47144  Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into two partial liver grafts (ie, left lateral segment (segments II and III) and right trisegment (segments I and IV through VIII))
47145  Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into two partial liver grafts (ie, left lobe (segments II, III, and IV) and right lobe (segments I and V through VIII)).
The main differences in these codes are whether the liver graft was obtained from a living or cadaver donor, and if the liver is split or not. It is important to make sure that the physician’s documentation indicates what form of backbench was performed. There are two backbench reconstruction codes to use when the liver graft requires venous or arterial reconstruction. Previously procured iliac veins from the donor are anastomosed to the veins or arteries of the donor liver graft. These codes are:
47146  Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each
47147  Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each
Use these codes for each anastomosis performed during donor vessel reconstruction.
Aortic conduit creation is another reconstruction that can be performed and is used for extremely complex cases where the recipient’s vascular anatomy would not support liver graft placement or if the graft does not lend itself to standard transplantation placement. The procedure is performed by using the iliac artery procured from the donor, which consists of a common iliac artery, an external iliac artery, and an internal iliac artery. To join the vessels together to make the graft longer the physician uses anastomoses.
As a solution to this coding challenge it was determined in our facility that to bill appropriately for this procedure, the unlisted code 37799 Unlisted procedure, vascular surgery is reported and compared to the code 47147, and assigning one unit per anastomosis required to create the graft. The rationale for coding this way is because the procedure is performed on the backbench and separate from the donor graft itself, so the standard reconstruction codes do not apply for this procedure.
Prior to the donor graft placement, the recipient’s liver must be removed and the abdomen prepared for graft placement. In preparing the abdomen, a temporary portacaval shunt is performed by partially occluding the vena cava and performing an end to side portacaval shunt using sutures. Even though this is a temporary shunt, the full procedure is performed per the CPT^® definition of code 37140 Venous anastomosis, open; portocaval. It is billable in addition to the transplant codes themselves.
The standard liver transplantation codes are:
47135  Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age
47136  Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age
Orthotopic is graft placement in the same anatomical location as the original organ. Heterotopic is graft placement in an abnormal anatomical location. Since it is most common for the liver graft to be placed in the normal anatomic location in the recipient, code 47135 is the most commonly used code. Due to the history of poor outcomes with heterotopic placement the practice has all but been abandoned. The transplant surgeon should indicate which type of transplant occurs, if the information is not clearly indicated in the documentation of the anatomic position the liver graft was placed, for example, in the abdomen or the pelvis, then clarification is needed from the surgeon. Codes 47135 and 47136 include the partial or whole recipient hepatectomy, partial or whole transplantation of the allograft and the recipient care.
Additional Procedures
During transplantation, additional procedures maybe performed. For example, a Roux-en-Y procedure may be performed due to anatomic variances in the graft, the recipient, or both. The procedure can be of the extrahepatic biliary ducts or of the intrahepatic biliary ducts. The CPT^® codes available for these procedures are:
47780  Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract
47785  Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract
If an aortic conduit is created and placed in the patient (an additional procedure as well), this may be billed with the code 37799, depending on where the conduit was placed and what vessels were attached to the conduit. If there is, a code for the anastomosis performed with the conduit the code range will be 35631–35636 because the graft is created using arteries from the donor and not from the recipient.
These codes, in addition to the code 37140, would have a modifier 51 Multiple procedures added to indicate these are multiple procedures in addition to the base transplant codes depending on the payer. Most payers have software to recognize these instances automatically and would not require the coder to apply modifier 51.

Immunosuppression Therapy

After the procedure is complete, the patient will need to be monitored and immunosuppression therapeutic medications will be adjusted by the transplant surgeon throughout the patient’s stay. These subsequent hospital visits are billable per CMS guidelines as long as they are truly significantly, separately-identifiable from a standard postoperative visit and indicated by the use of modifier 24. To know if the visit would be billable under this guideline, for example, check if the documentation outlines the immunosuppression drugs used, any side-effects caused by the therapy, and/or if any modifications are required. The note should not include any references to wound checks or other standard post-operative care plans. For the best outcome, the coder might suggest using two notes, one for the immunosuppression and a separate note for the post-operative follow-up note.

Liver Transplant Awareness

There are currently 100,665 people on the waiting list for organ transplant; every 11 minutes a name is added to the national transplant waiting list. To learn more about organ donation or to sign up to become a donor please visit www.donatelife.net.
Sources:
American Liver Foundation
(www.liverfoundation.org/education/info/alcohol/)
United Network for Organ Sharing
(http://unos.org/whatWeDo/organCenter.asp)
Coders’ Desk Reference for Procedures; 2009; published by Ingenix
Special thanks for clinical assistance to: William Chapman, MD, professor of surgery in the Division of General Surgery, and chief of the Abdominal Transplantation Section for Washington University Medical School in St. Louis, Mo. and also to Christopher Anderson, MD, assistant professor of the Surgery Division of General Surgery Section of Transplant Surgery for Washington University Medical School in St. Louis, Mo.

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