General Surgery Coding Alert

Although a surgeon generally may not bill additional codes for complications during surgery, he may access modifier -22 (Unusual procedural services) to gain additional payment.
 
"If a surgery requires significant additional time or effort that falls outside the range of services described by a particular CPT code, that's the time to apply modifier -22," says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company.
 
For example, during laparoscopic chole-cystectomy (lap chole), the surgeon must lyse extensive adhesions. In this case, the surgeon may not claim 44200 (Laparoscopy, surgical; enterolysis [freeing of intestinal adhesion] [separate procedure]) in addition to the lap chole because the National Correct Coding Initiative (NCCI) bundles the procedures. But if the surgeon spent significant additional time lysing adhesions (in other words, if the adhesions added at least 25 percent additional time or effort beyond that typically required for a lap chole), you may report the appropriate lap chole code with modifier -22 attached. 
 
In a second example, during a routine laparoscopic gallbladder surgery (lap chole), the surgeon finds that there are a few stones in the patient's common duct that take an additional two hours to remove through the scope. There are no extra codes to report in this case, so you would append modifier -22 to 47564 (... cholecystectomy with exploration of common duct), says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif.

Only Report Open Procedure for Conversions

When a surgeon converts a lap chole to an open procedure, CMS and CPT coding guidelines dictate that you may report the open procedure only. Just as in the above scenarios, however, if the surgeon spends considerable additional time or effort performing a laparoscopic procedure before converting to an open procedure, you may append modifier -22 to the open procedure code.
 
Note that modifier -22 is not warranted for all conversions: To gain additional payment, the surgeon's documentation must firmly establish why the additional effort was necessary.
 
For example, the surgeon begins a lap chole but, due to the severe obesity of the patient, the scope could not pass through the incision. Therefore, the physician decides to change to an open procedure. In this case, you may report the open procedure only (47600, Cholecystectomy), Fletcher says. If the surgeon's documentation provides sufficient evidence that the open procedure required significant additional time or work because of the patient's obesity (or other reasons) you may append modifier -22 to 47600.
  
Tip: When reporting an open procedure that the surgeon has converted from a laparoscopic procedure, be sure to add V64.41 (Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis.

Don't Forget Cholangiography

Surgeons often perform cholangiography as a standard component of cholecystectomy. Because of this, many surgeons fail to note at the top of the operative report that they included cholangiography. "The top of the operative report may list 'laparoscopic cholecystectomy' only, but sometimes the procedure notes in the operative report also reveal that the surgeon performed cholangiogram," Cobuzzi says.
 
Failing to report cholangiography can cost valuable reimbursement dollars and compromise the medical record. "That's why it is important to read the body of the operative note," Cobuzzi says.