Robotic Surgery: Standard Coding Describes High Tech Approach

The Food and Drug Administration (FDA) approved the first fully-robotic surgery device, the da Vinci® surgical system, in early 2000. In recent years, robotic surgery—technically called laparoscopic robotic-assisted surgery—has revolutionized minimally invasive surgery (MIS).

Robotic-assistance has been adopted by several surgical specialties for complex procedures, such as mitral valve repair, Roux-en-Y, prostectomy, hysterectomy, sacral colpopexies, coronary anastomosis, nephrectomy, and others.

Standard Procedure

The da Vinci® surgical system, manufactured by Intuitive Surgical, Inc., allows a surgeon to operate while seated at a console. The surgeon views the surgical field through a 3-D eyepiece while his fingers grasp the instrument controls below the display, which in turn direct a robotically-controlled laparoscope. The surgeon’s movements are translated, precisely and in real time (but minus hand tremor, according to the device manufacturer), to the articulating laparoscopic robotic instruments. The device cannot be programmed, and remains under the surgeon’s direct control at all times.

The da Vinci® sports four praying mantis-like arms projecting from a unit at the head of the table. A surgeon and operation room (OR) technicians attach special surgical instruments, cameras, tubes, and other items to the arms. While an anesthesiologist monitors the patient, the primary surgeon sits at a console near the OR table. An assistant surgeon stands at the OR table next to the patient. Hand and foot controls allow the primary surgeon to move the robotic arms and attachments through tiny incisions. The surgical field is visible via a 3-D view from the cameras on the arms. According to Intuitive Surgical, “Operating images are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units.”

Although expensive (in excess of $1 million for the device alone, not including maintenance, surgeon training, and other costs), the da Vinci® offers numerous technical advantages to surgeons and patients, alike. Surgeons may benefit from improved precision and less fatigue, while patients can experience lower risks, improved outcomes, and faster recovery—especially when compared to open surgical techniques.

Proponents say the da Vinci® system expands the breadth of laparoscopic procedures, which are restricted by conventional rigid laparoscopic instruments that only offer two-dimensional views and are hampered by the surgeon’s hand tremor during delicate maneuvers with straight non-rotating instruments. More complex procedures requiring delicate fine-tissue manipulation, lymph node retrieval, maneuverability in tight pelvic spaces, extensive dissection and critical suturing can be done by the surgeon with robotic laparoscopic instruments.

The manufacturer of the system says it is the fastest growing treatment for prostate cancer and tells Coding Edge there are 1,242 da Vinci® systems installed, 916 of those are in the United States. The technology is proving successful and popular; and it, in the same way the laptop computer changed our lives, may change how surgery is done.

Straightforward Coverage

The procedure may sound exotic, but coding laparoscopic robotic-assisted surgery claims isn’t. The primary surgical procedure is laparoscopic and is covered by routine and customary laparoscopic CPT® and ICD-9-CM coding practices. There is no need for unlisted procedure codes or modifier 22 Increased procedural services for robotic assistance (unless, of course, there is no existing laparoscopic code to describe a procedure).

Note: Many leading payers have specific medical policies about robotics. Rates are influenced by the hospitals’ contract terms that preceded acquisition of the robot. However, hospitals have been successful with updating contract terms.

Any insurance covering MIS (including Medicare) generally covers robotic surgery. Unfortunately, many leading payers do not permit an additional payment allowance for the robotic surgical technique.

For instance, if the surgeon uses robotic-assist to perform a laparoscopic myomectomy of two myomas weighing a combined 100 grams, the appropriate code is 58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas. The payment for the robotic component is considered part of the global surgical service.

In a second example, if the surgeon performs a laparoscopic radical, nerve sparing prostatectomy with robotic assistance, the appropriate code is 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing.

If your payer accepts HCPCS Level II S codes, you may report S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) in addition to the primary procedure code, to identify the procedure as robotic-assisted. Note that S codes are not payable under Medicare, and likely won’t result in additional payment from leading insurers, such as CIGNA and United Healthcare. (For consideration, CIGNA and United Healthcare have “robotic surgery” reimbursement policies).

In the institutional setting, a series of ICD-9-CM procedure codes to identify robotic-assisted procedures became effective Oct. 1, 2008:

• 17.41 Open robotic assisted procedure
• 17.42 Laparoscopic robotic assisted procedure
• 17.43 Percutaneous robotic assisted procedure
• 17.44 Endoscopic robotic assisted procedure
• 17.45 Thoracoscopic robotic assisted procedure
• 17.49 Other and unspecified robotic assisted procedure

These codes are used in addition to the appropriate code to describe the primary procedure. For instance, to report a laparoscopic total abdominal hysterectomy with robotic-assistance, assign 68.41 Laparoscopic total abdominal hysterectomy, cholecystectomy followed by 17.42.

Brad Ericson, MPC, CPC, COSC, is AAPC’s director of publications.
G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.

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