General Surgery Coding Alert

"General surgeons typically do not perform many endoscopic explorations of the small intestine and may be unfamiliar with the unique coding involved in billing such procedures.

Many coders dont know what to look for in the CPT manual because these codes arent found in the typical spots general surgery coders look, says Kathy Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.

Unlike colonoscopies, which surgeons perform routinely, these procedures arent performed often, and the codes are tucked away in a section of the CPT manual used more by gastroenterologists or urologists than general surgeons, Mueller says. Its important to be able to identify these codes correctly, based on the information in the op note, she says, because small bowel endoscopies are well-paid procedures.

In the following case study, the surgeon first performs an endoscopy of a previously created ileal conduit to rule out carcinoma. The scope doesnt find anything, so a day later an exploratory laparotomy with biopsy of an abdominal mass adjacent to, but not inside, the ileal conduit is performed. When the pathology report identifies the mass as cancerous, the surgeon excises it.

Operative Report No. 1

Preop diagnosis: Intra-abdominal mass, rule out tumor involving the ileal conduit
Postop Diagnosis: Same
Operations: Panendoscopy of the ileal conduit Loop-o-gram

OP finding/indications for surgery:

Patient has intra-abdominal mass on CT scan. Patient has known carcinoma of the bladder and previously underwent radical cystectomy with ileal conduit urinary diversion in 1994. A surveillance CT scan shows intra-abdominal mass. Repeat CT scan shows a large intra-abdominal mass, with possible tumor involving the ileal conduit. On panendoscopy, no tumor was identified within the ileal conduit. A loop-o-gram shows no filling defects inside the conduit itself, although there appears to be some extrinsic pressure, which would indicate that this tumor is an intra-abdominal mass, but not invading the conduit and incidental reflux of contrast into the right ureter.

Technique of operation:

A #22 french rigid cystoscope was introduced into the conduit. Panendoscopy was then performed. There is no definite tumor identified within the lumen of the ileal conduit. I was able to identify the ureteral orifice and I tried to cannulate it with a glide wire, but I could not advance it beyond the meatus. There was no tumor identified in the meatus or inside the conduit itself. Next, the cystoscope was removed. A #16 french foley catheter was then placed within the conduit, and the balloon was inflated to 5 cc. Fifty cc of contrast material was injected through the catheter and filled the loop. X-rays were taken and showed reflux of the contrast in the right ureter. No effusion into the left ureter. There are no filling defects inside the conduit itself. Post-drainage films also show no extravasation or filling defects. The instruments were then removed

Coding the First Operation

This operative session would be coded as follows, Mueller says.

44380 ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

50690 injection procedure for visualization of
ileal conduit and/or ureteropyelography,
exclusive of radiologic service

The diagnosis codes should include 593.4 (other ureteric obstruction), followed by 793.6 (nonspecific abnormal findings on radiological and other examination of body structure, abdominal area, including retroperitoneum) and V10.51 (personal history of malignant neoplasm, bladder). She further notes that the obstruction of the ureter, which should be listed as the primary diagnosis, is not listed at the top of the op note and would be discerned only by carefully reading the procedure note, in which the surgeon states that he was unable to cannulate the ureter because of extrinsic pressure on the ureter.

This means the obstruction most likely was due to the abdominal mass, Mueller says, and was confirmed by the injection procedure (loop-o-gram).

This operative session also shows how general surgeons can be called upon to perform out-of-the-ordinary procedures, such as, in this case, the scoping of an ileal conduit, says Tray Dunaway, MD, a general surgeon in Camden, S.C. He notes that the surgeons use of the term panendoscopy, while technically correct, actually describes a panendoscopy only of the specific segment of small intestine that now forms the ileal conduit, whereas the term usually is meant to describe the scoping of both the upper and lower gastrointestinal (GI) tract. This procedure perhaps could be termed better endoscopic inspection of all the ileal conduit, Dunaway says.

The insertion of the catheter into the conduit, followed by a contrast injection, constitutes the loop-o-gram, which Dunaway describes as a retrograde contrast study. Although neither the endoscope nor the loop-o-gram revealed anything within the ileal conduit, the patient still is obstructed, and the previous CT scan did indicate the presence of a mass. The next day, the patient was back in surgery.

Operative Report No. 2

Preop diagnosis: Intra-abdominal mass, rule out metastatic tumor
Postop diagnosis: Intra-abdominal mass positive for carcinoma by frozen section plus adhesions
Operations: Exploratory laparotomy, lysis of extensive adhesions, biopsy of intra-abdominal mass and excision of the intra-abdominal mass

OP finding/indications for surgery: (Same patient history as in previous op note.)

After 1 hours of lysing extensive adhesions, large mass adjacent to the ileal conduit measuring approximately 6 x 8 cm was found. Most of the tumor is underneath the ileal conduit and mostly adherent to some omentum and small bowel. At that point, I asked the doctor, a urologist, to consult and he recommended that we biopsy the tumor. We removed a wedge of tissue from the mass and this was sent to pathology for frozen section. After 40 minutes, the frozen section revealed carcinoma. At that point, we decided to resect the tumor since it was already impinging the conduit. We were able to excise the tumor in toto. It appears to be mostly vascularized by the omentum Total time of the procedure was four hours.

Technique of operation:

A #16 french foley catheter was placed into the conduit for drainage and to be able to delineate the conduit. An incision was then made following the old incision. The incision was carried down through subcutaneous tissue down to the fascia. The peritoneum was then opened and at this point the large intra-abdominal mass was identified. With a combination of blunt and sharp dissection, the adhesions were lysed from the small bowel. Also the omentum was firmly attached to this tumor and appears to be vascularized from the omentum. After tumor was excised, careful inspection of the abdominal cavity reveals no injury to the bowel or to the conduit and there was no injury to the ureters or to the conduit. The incision was then copiously irrigated with sterile water. The incision was then closed

Coding the Second Operation

This operative session would be coded as follows, Mueller says:

49201-58 excision or destruction by any method of intra-abdominal or retroperitoneal
tumors or cysts or endometriomas;
extensive, staged or related procedure
or service by the same physician during the postoperative session

49000 exploratory laparotomy, exploratory
celiotomy with or without biopsy(s)(separate procedure)

Because the frozen section indicates carcinoma but the source is not described, the correct diagnosis code for both procedures would be either 195.2 (malignant neoplasm of other and ill-defined sites, abdomen) or 197.6 (secondary malignant neoplasm of respiratory and digestive system, retroperitoneum and peritoneum).

Note: The ICD-9 codes from the first session also could be included as secondary diagnoses.

In this case, the origin of the tumor was unknown prior to the start of the procedure, and the surgeons waited to get the results of the frozen section before proceeding with the more extensive surgery (the excision), says Mueller.

As a result, the biopsy can be deemed truly diagnostic and therefore separately billable, according to the General Correct Coding Policies section of version 6.2 of HCFAs Correct Coding Initiative, which states: If the decision to perform a more comprehensive procedure is based on the biopsy result (i.e., the biopsy is diagnostic), then the biopsy service may be separately reported.

Use Modifiers Carefully

Mueller also notes that modifier -58 (staged or related procedure or service by the same physician during the postoperative period) could be appended to 49201 because it was staged to the laparotomy with the biopsy that took place earlier during the same session. Alternatively, modifier -59 (distinct procedural service) could be added to the 49000 to indicate that in this case the procedures are distinct and shouldnt be bundled. Determining which modifier to use is carrier-specific, although many Medicare carriers recommend attaching modifier -58 to 49201. Even so, Mueller adds, there is a strong possibility that one of the procedures will be denied. If the claim is denied, a clearly written operative report should help adjudicate any such denial.

Mueller also points out that lysis of adhesions is bundled to the primary abdominal procedure. In this case, even though the amount of time spent lysing adhesions (one and a half of a total of four hours) is unusual, modifier -22 (unusual procedural services) could not be added appropriately to 49201 because the definition of this code already includes the term extensive. According to Coders Desk Reference, 49201 is used when the procedure is extensive, involving numerous or large growths, or a significantly greater amount of time than usual.

Dunaway agrees that complicated, unusual operative sessions like those described above clearly illustrate the need for accuracy when describing procedures and findings in operative reports. This was an unknown malignancy arising from unknown origins, not a typical or easy scenario for a general surgery coder, he says. The more unusual the circumstances, the better the documentation should be. The coder cant, and shouldnt have to, read between the lines, especially if the lines are new and different from usual."