General Surgery Coding Alert

Don't stay in the dark about Medicare's latest surgical bundles or you might face denials when your surgeon performs aneurysm repair and AV fistula revision together.

Version 15.3 is the last Correct Coding Initiative (CCI) update of the year -- but that didn't stop CMS from adding over 16,000 edit pairs to the surgery section.

Don't panic: That's a lot of code bundles, but our experts have distilled all those restrictions into four categories you need to know to avoid pitfalls for your surgery practice.

CCI 15.3 bundles moderate sedation codes 99148-+99150 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports ...) with just about every surgical procedure code your surgeon might use. In fact, roughly 80 percent of the new bundles relate to these three codes, according to the "NCCI 15.3 Update" news release by Frank Cohen, MPA, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

These edits carry a modifier indicator of "0," which means you can't override the bundled codes.

The large number of 99148-+99150 edit pairs continues the trend toward rarely paying separately for conscious sedation, notes Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

Good news: Don't start counting the dollars you'll be losing. As the 99148-+99150 descriptors indicate, these codes represent sedation by a second physician -- not by the physician performing the diagnostic or therapeutic service. So those edits shouldn't change how you code your surgical procedure claims.

You'll also see some new bundles for +99145 (Moderate sedation services ...provided by the same physician ... each additional 15 minutes intra-service time). For example, CCI bundles +99145 into 35470-35476 (Transluminal balloon angioplasty, percutaneous ...). But your CPT manual or software should alert you that CPT considers moderate sedation included in this service, meaning you shouldn't be reporting +99145 with these codes anyway.

CCI 15.3 continues the trend of adding bulky lists of fluoroscopy edits to the file. This round, CCI focuses on 76000 (Fluoroscopy, [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) and 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy).

The logic: These edits emphasize that when physicians use fluoroscopy to enhance visualization in scope procedures such as 38120 (Laparoscopy, surgical, splenectomy), the surgical service includes the guidance, according to Bucknam.

Some of the new edit pairs simply enforce how you should have been coding all along. For instance, CCI 15.3 bundles 76001 with 10021 (Fine needle aspiration; without imaging guidance). "Clearly, you should not bill guidance with 10021," Bucknam says, because the code definition states, "without imaging guidance." CPT provides a separate code for FNA procurement that involves imaging guidance: 10022 (...with imaging guidance).

If you have a patient with an arteriovenous (AV) fistula who requires an aneurysm repair, you'll have to navigate some new CCI edits. You'll find the following three codes in column 1:

• 35011 -- Direct repair of aneurysm, pseudoaneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision

• 35013 -- ... for ruptured aneurysm, axillarybrachial artery, by arm incision

• 35045 -- ... for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery. They're bundled with each of these three codes in column 2:

• 36832 -- Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)

• 36833 -- ... with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)

• 36834 -- Plastic repair of arteriovenous aneurysm (separate procedure).

Here's why: You should only list 36832-36834 when your surgeon performs a truly "separate procedure." An aneurysm repair and AV fistula revision at the same site are interrelated, and also both deal with associated occlusive disease, according to Bucknam.

But you can override these edit pairs, when appropriate. "For example, if the patient has a dialysis fistula in one arm and an aneurysm at a separate location, you can unbundle the services using modifier 59 (Distinct procedural service)," Bucknam says.

Tip: Always check the modifier indicator column in the CCI file before unbundling codes. The modifier indicator "1" means that you can override an edit with a modifier when appropriate, says Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, manager at Pershing Yoakley & Associates P.C. in Clearwater, Fla.

CCI 15.3 bundles several percutaneous procedure codes with the similar open-procedure code. For example, you find 35470 (Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel) bundled with 35459 (Transluminal balloon angioplasty, open; tibioperoneal trunk and branches).

These edits should help keep your coding on the straight and narrow rather than changing your day-to-day practices if you've been coding correctly all along. "If a surgeon attempts a less-invasive technique, such as percutaneous procedure, but requires more exposure and converts to an open procedure, you should only report the most extensive (open) service," Bucknam says.

General Surgery Coding Alert/2009, Vol. 11, No. 14 To subscribe, call (800) 508-2582 Page 107 Tip: "Coders should be aware that if the surgeon documents extra time and work for a converted procedure, modifier 22 (Unusual procedural services) might be appropriate," Bucknam adds.