General Surgery Coding Alert

Good news: Edits shouldn't take a serious toll on your reimbursement bottom line.

The Correct Coding Initiative (CCI), version 15.0, sets its sights on the new 2009 codes rather than adding many new edits for your established codes. Checking the modifier indicator one key to navigating the new edits. Read on for more tips.

You-ve learned to expect that new CPT codes bring new bundles from CCI. The laparoscopic hernia repair codes are no exception. CCI 15.0 bundles a slew of codes into 49652 (Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia [includes mesh insertion, when performed]; reducible), 49653 (-incarcerated or strangulated), 49654 (Laparoscopy, surgical, repair, incisional hernia [includes mesh insertion, when performed]; reducible), 49655 (-incarcerated or strangulated), 49656 (Laparoscopy, surgical, repair, recurrent incisional hernia [includes mesh insertion, when performed]; reducible), and 49657 (-incarcerated or strangulated).

CCI bundles the six new lap hernia repair codes with 36000 (Introduction of needle or intracatheter, vein), 36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]), and 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]). All of these bundles have a modifier indicator of "1," meaning that you can override these edits with a modifier under the proper circumstances.

The new bundles between 49652-49657 and 43653 (laparoscopic gastrostomy), 44180 (laparoscopic enterolysis), 49320 (diagnostic laparoscopy), 49560 (initial hernia repair), 49565 (recurrent hernia repair), 58660 (laparoscopic lysis of adhesions), and 69990 (microsurgical techniques) all have a modifier indicator of "0," however. A "0" indicator means that you may not unbundle the edit combination under any circumstances, according to CCI guidelines. (See the chart on page 36 for additional bundles for the new laparoscopic hernia repair codes.)

Silver lining: The laparoscopic hernia repair bundles are "pretty intuitive," says Charlotte T. Tweed, RHIA, CPC, inpatient coder in the department of medical education/coding at Florida Hospital in Orlando. "I don't think a surgery coder would have much trouble with any of these edits." Tweed says the edits mirror these standard coding guidelines:

1. As with most laparoscopic procedures, you wouldn't report both a laparoscopic code and an open code.

2. You would not code repairs of approaches as you come back out.

3. Coding rules routinely include lysis of adhesions with other procedures, and you should not code them separately unless there are extensive problems requiring significant extra time.

4. You would not use the mesh code (49568) with the lap hernia codes because they specifically state mesh is included with that code. Reporting 49568 would be double billing for the mesh, Tweed explains.

In addition: You-ll also now find that the not-so-new laparoscopic repair codes for inguinal hernias (49650, Laparoscopy, surgical; repair initial inguinal hernia and 49651, ... repair recurrent inguinal hernia) face new edits this quarter. CCI now bundles both codes with 49650 and 49651 with 58660 (Laparoscopy, surgical; with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]) with a modifier indicator of "0."

CCI also hits the new hemorrhoid destruction code 46930 (Destruction of internal hemorrhoid[s] by thermal energy [eg, infrared coagulation, cautery, radiofrequency) several bundling edits. You won't be able to report 46930 with anesthesia code 00902, manipulation codes 45900-45915, anorectal exam code 45990, and more. You-ll be able to use a modifier to break some of the new 46930 bundles -- for example, the bundle with nerve block codes 64415-64417 and new therapeutic, prophylactic, and diagnostic administration codes 96360-96375. (See the chart on page 36 for more details.)

"We were hoping the new hemorrhoid destruction code wouldn't be bundled into a lot of other codes," says Heather Corcoran, coding manager for CGH Billing in Louisville, Ky. "This is unfortunate but shouldn't take too much reimbursement away from us."

Many of the new code edits have a modifier indica-tor of "1." This means that you can unbundle these edits with the proper modifier under the appropriate clinical circumstances.

Although you can bypass many of the bundles with modifier 59 (Distinct procedural service), you must meet the criteria for doing so, says Debra Pierce, MD, MBA, CPC, founder and managing member of Pierce MD Consulting LLC in Rockbridge, Ohio. CPT 2008 revised the modifier's descriptor, specifying, "Documentation must support:

Caution: "CMS has improper use of modifier 59 on its radar screen and practices are well-advised to exercise due caution in using this modifier," Pierce cautions.

Remember: Although you can bypass many of the bundles using modifier 59, this is the modifier of last resort. CPT warns that you should not use modifier 59 "when another already established modifier is appropriate, unless no more descriptive modifier is available, and so long as it best explains the circumstances," Pierce says.

CCI bundles the new revised therapeutic, prophylactic, and diagnostic administration CPT codes 96360 (Intravenous infusion, hydration; initial, 31 minutes to one hour), 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour), 96372-96375 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug] -) into most of the surgical procedures your surgeon might perform, including 10040-10180 (incision and drainage) and 49652-49657.

Good news: The modifier indicator for all of these new bundles is "1," meaning that you can override these edits with a modifier under the proper circumstances. (For more on overriding CCI bundling edits, see "Learn When You Can Legitimately Override CCI Edits" on the right.)

Same bundles, different codes: The 2009 therapeutic, prophylactic, and diagnostic administration codes replaced the 2008 CPT intravenous and injection codes 90760, 90765, 90772, 90774, and 90775. The CCI 15.0 bundles for the new codes mirror the same bundles that CCI placed on the old 2008 drug administration codes.

Plus: You-ll also be out of luck if you try to report conscious sedation codes 99143-99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status -) with any of the codes from the 49440-49442 series (tube placement). Medicare payers will deny the conscious sedation charge, and no modifier can separate the bundles.

"With each edition of CCI comes more codes that are forbidden to report with conscious sedation," says Aran Hicks, billing consultant for six practices in Raleigh, N.C.

Want to learn more? To download a free copy of CCI 15.0 go online to www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.