General Surgery Coding Alert

Before you're done prepping to use the new CPT 2010 general surgery codes, the latest edition of Medicare's Correct Coding Initiative (CCI) is already making some code pairings impossible.

CCI released version 16.0, effective Jan. 1, which includes 24,060 new active pairs and 869 modifier changes, according to Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions.

Most of the code pairings -- and deletions -- affect codes that debuted or exited in CPT 2010. Round up all the general surgery edits you need to know with just three expert tips.

With 72 new/revised codes for soft tumor excisions and resections, CCI found plenty of fodder for edit pairs that will impact your practice.

Mutually exclusive edit pairs -- those that a physician would not reasonably performat the same session -- include bundling all soft tissue excision codes with debridement procedures involving subcutaneous tissues, muscle fascia, muscle, or bone (11010-11012, Debridement including removal of foreign material associated with open fracture[s] and/or dislocation[s] ...). You'll also find mutually exclusive edit pairs for the soft tissue codes and lymph node excision/resection codes specific to the same anatomic site.

Column 1/column 2 edit pairs abound with the new soft tumor codes too, often representing comprehensive/component code pairs.

For instance: CCI 16.0 bundles soft tissue tumor excision codes with skin repair codes for the same anatomic site in the range 12001-13152, describing simple, intermediate, and complex closure.

The fact that some skin surgery codes, such as 12001-12007 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities[including hands and feet]; ...), now bundle into the new tumor excision codes "makes perfect sense," says Randall Karpf, coding consultant with East Billing in Connecticut. "A simple repair can be done during the course of the excision, so you'd bundle it unless the separate encounter or site rules apply."

Use modifier for separate sessions or sites: If the surgeon performs truly distinct procedures, such as 21011 (Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm) and simple repair of a leg wound (such as 12001, ... 2.5 cm or less), you can override the edit pair by appending modifier 59 (Distinct procedural service) to 12001.

As with other new surgery codes, CCI 16.0 bundles the soft tumor excision codes with a host of procedures, such as intravenous (IV) needle or catheter insertion (36000), that Medicare considers part of the surgical procedure. You'll find a more complete discussion of these bundles in "Tip 2."

Medicare specifies that when you bill a surgical code, the procedure includes all intraoperative services that are usual and necessary parts of the surgery. That's why CCI 16.0 lists "standards of surgical practice," as the reason for many new code pairs with the following new CPT 2010 general surgery codes:

• 43281 and 43282 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed;...)

• 43775 (Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy [i.e., sleeve gastrectomy])

• 45171 and 45172 (Excision of rectal tumor, transanal approach; ...)

• 46707 (Repair of anorectal fistula with plug [e.g.,porcine small intestine submucosa [SIS])

• 49411 (Placement of interstitial device[s] for radiation therapy guidance [e.g., fiducial markers, dosimeter], percutaneous, intra-abdominal, intra-pelvic [except prostate], and/or retroperitoneum, single or multiple).

Know the column 2 codes: With the above new surgical codes as column 1 codes, CCI 16.0 creates edit pairs with the following procedures that Medicare considers usual and necessary parts of surgery:

• Venipuncture, IV, infusion, or arterial puncture services represented by codes such as 36000, 36400- 36440, 36600-36640, and 37202

• Naso- or oro-gastric tube placement (43752)

• Bladder catheter placement (51701-51703)

• Many injection codes in the range 62310-64530

• Operating microscope (69990)

• Many electrocardiogram (ECG) and evaluation and management (E/M) codes.

You should never unbundle these code pairs because CCI assigns a "0" modifier indicator.

Unrelated to any new codes, CCI 16.0 places harsher restrictions on some existing code pairs by changing the modifier indicator.

The bad news: CCI 16.0 eliminates your chances of collecting for both pancreatotomies (48150-48154) and certain cholecystectomies (47605-47610). Although previous versions of CCI gave these pairings a "1" modifier indicator (meaning you could use a modifier to override the edits), the pairs earn a "0" modifier indicator (meaning you can't override the edit pairs for any reason) effective Jan. 1.