Laparoscopic to Open Procedures: Look Ahead to ICD-10

Understand how losing subcategory V64.4x will affect reporting of converted surgical approaches.

By Jennifer E. Avery, CPC-H, CPC, CPC-I, CCS
The Centers for Medicare & Medicaid Services (CMS) instructs us that when a procedure begins by laparoscopic approach, but must be converted to (and completed by) open approach, only the open approach is coded.
In ICD-9-CM, an additional diagnosis from subcategory V64.4x (Closed surgical procedure converted to open procedure) is reported to indicate that the physician changed the approach midstream. The fifth digit identifies the type of “closed” procedure (i.e., V64.41 Laparoscopic surgical procedure converted to open procedure). This rule applies to inpatient and outpatient services, as well.
No code has been created in ICD-10-CM that mirrors V64.4x. So post Oct. 1, 2014, how will the physician identify a lap-to-open procedure appropriately? Let’s investigate the situation to understand the disconnect between physician and facility.
ICD-10 Means Distinct Coding for Physician, Facility
ICD-10-PCS for inpatient facility includes procedure coding guidelines that disconnect how the surgeon reports procedures and services using CPT® guidelines, and how the facility reports the same procedure and services performed on an inpatient.
ICD-10-PCS Coding Guidelines, B3.2.d, instructs us to report multiple procedures when the intended root operation is attempted using one approach, but is converted to a different approach. For example, if a physician begins a laparoscopic cholecystectomy, but determines that he or she needs to convert to an open cholecystectomy, the facility would report two procedures: an open cholecystectomy and a laparoscopic inspection (i.e., diagnostic laparoscopy). The facility potentially has more resources involved, so the change in how the facility should report seems appropriate and understandable.
There is no indication that this rule will change for the physician; following CMS guidance, the physician will still report only the open cholecystectomy (CPT® 47600 Cholecystectomy). The diagnostic laparoscopy is considered a component of the procedure, based on CPT® guidelines that state diagnostic laparoscopy is always included in therapeutic laparoscopy. The physician expects “look around” as a component of the performed procedure, which does not warrant additional work value (i.e., multiple CPT® codes).
CPT® Assistant Offers Possible Answers
CPT® Assistant, “A Review of the Laparoscopy/Hysteroscopy Changes,” March 2003, indicates that reporting of laparoscopic procedures converted to open procedures may vary depending on the scenario, and provides a set of general guidelines to follow:

Questions are often received regarding the appropriate way to report an attempted laparoscopic cholecystectomy that is converted to, and completed as, an open procedure. As with coding any “attempted” procedure, it is necessary to carefully review the operative report to determine the extent of the procedure(s) performed in order to accurately code for the procedure(s).
Appropriate coding may vary on a case-by-case basis, depending on the specific circumstances in each case.
1. Under certain circumstances, physician may “elect” to terminate a surgical procedure (i.e., laparoscopic cholecystectomy) due to extenuating circumstances or due to things that threaten the well being of the patient. If the procedure is started but discontinued due to these circumstances, report the procedure with the modifier -53, discontinued procedure.
2. In other situations, at physician’s discretion (not related to extenuating circumstances), a procedure may be partially reduced or eliminated. These circumstances should be reported with the modifier -52, reduced services.
3. When a specific circumstance indicates a conversion of the laparoscopic procedure to an open procedure, it is appropriate to report the code for the “attempted” laparoscopic procedure (i.e., laparoscopic cholecystectomy) with the appropriate modifier appended. The code for the open cholecystectomy is reported as the primary procedure with the modified laparoscopic procedure code reported as a secondary procedure. Per CPT, this method of reporting allows for the accurate tracking and reporting of the specific procedure(s) performed. Individual third-party payer policies may vary (i.e., CMS guidance as indicated above).

Determine Its Effect on Your Practice
Look at your practice and identify how often such a scenario occurs, and whether this affects your Medicare population vs. your commercial insurance population. Then, query the various third-party payers to determine appropriate reporting. If your practice follows the guidance of the National Correct Coding Initiative Policy Manual for Medicare Services, consider contacting the cooperating parties before ICD-10 implementation to question the rationale regarding no corresponding code in ICD-10-CM.
Reporting only the open procedure without the corresponding status code could potentially affect the statistical reporting and tracking accuracy of specific circumstance. This may be a product of creating ICD-10-PCS guidelines and codes without considering the affect it has from a physician and facility outpatient reporting perspective.

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Jennifer E. Avery, CPC-H, CPC, CPC-I, CCS, is a senior regulatory specialist for HCPro, Inc., and an instructor for Certified Coder Boot Camp®, Certified Coder Boot Camp® Online, Certified Coder Boot Camp® – Inpatient Version, HCPro ICD-10 Beyond the Basics Boot Camp®, and Certified Coder Boot Camp® – ICD-10-CM & ICD-10-PCS. She holds an associate degree in Health Claims Management and Medical Assisting from Davenport University, Granger, Ind., and is working on a Bachelor of Science in Health Information Management. Avery is a member of the St. Louis West, Mo., local chapter.
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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