General Surgery Coding Alert

Pay attention to more specific 'abdominal' CPT^® sections, too.

Before you consider billing a diagnostic gastric intubation and aspiration with any upper GI endoscopy, you better check the latest Correct Coding Initiative (CCI) edits. That's because the update includes over 20 new edit pairs with 43756 (Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen [e.g., bile study for crystals or afferent loop culture]), along with lots of other changes you need to know about now.

CMS released CCI version 18.2, effective July. 1, revealing 2,521 new active pairs and only 88 code pair deletions, according to Frank D. Cohen, MPA, MBB, senior analyst with Frank Cohen Group, LLC.

Choose One Hernia Code

After moving open hiatal hernia repair codes from CPT®'s diaphragm section to the esophagus section in 2011, CCI edits are catching up with a host of new edit pairs. All of the following new edit pairs have a modifier indicator of "0."

CCI 18.2 bundles open hernia repair codes 43332-43337 (Repair, paraesophageal hiatal hernia [including fundoplication] ... except neonatal...) and lap hernia repair codes 43281-43282 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; ...) with the following diaphragmatic hernia codes:

• 39503 -- Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia
• 39540-39541 -- Repair, diaphragmatic hernia (other than neonatal), traumatic; ...

"The new bundles essentially require you to code how you should anyway -- choose just the one hernia code that most closely describes the procedure your surgeon performs," says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

You'll also find new edit pairs that restrict using the hiatal hernia repair codes with stand-alone fundoplasty codes, as follows:

• 43280 -- Laparoscopy, surgical, esophagogastric fundoplasty (e.g., Nissen, Toupet procedures)
• 43327-43328 -- Esophagogastric fundoplasty partial or complete; ...

"The hiatal hernia repair code definitions include fundoplasty, so even before these CCI edits, separately reporting a fundoplasty would have been inappropriate," Bucknam says.

Include Intubation and Aspiration

When you report any procedure in the range 43234-43259 (Upper gastrointestinal endoscopy ...) performing a duodenal intubation and aspiration is included, according to CCI 18.2.

You'll find 43756 as a column 2 code to each of the upper GI endoscopy codes, indicating that the intubation and aspiration is a component of the more extensive service.

About half of the edit pairs have a modifier indicator of "0," meaning that you cannot override them under any circumstances.

CCI 18.2 also bundles together other duodenal and gastric intubation and aspiration codes in the range 43754-43757. Plus, you'll find new edit pairs for 44500 (Introduction of long gastrointestinal tube [e.g., Miller-Abbott] [separate procedure]) with 43756-43757.

Distinguish Fiducial Marker, Catheter Location

Several codes from disparate CPT® sections describe placement of fiducial markers, tunneled catheter, and subcutaneous port. Multiple new edit pairs from the mutually exclusive and non-mutually exclusive tables restrict how you can use these codes.

For instance: You shouldn't report together abdominal introduction codes 49411-49412 (Placement of interstitial device[s] for radiation therapy guidance [e.g., fiducial markers, dosimeter],...) with each other (percutaneous versus open approach) or with similar laparoscopy code +49327 (Laparoscopy, surgical; with placement of interstitial device[s] for radiation therapy guidance [e.g., fiducial markers, dosimeter], intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple [List separately in addition to code for primary procedure]).

CCI also bundles +49327 from the abdomen/peritoneum/omentum section with codes from CPT® sections describing more specific parts of the abdominal region as follows:

• Stomach section:

43653 -- Laparoscopy, surgical; gastrostomy, without construction of gastric tube (e.g., Stamm procedure) (separate procedure)

• Intestines section

44005 -- Enterolysis (freeing of intestinal adhesion) (separate procedure)

• 44180 -- Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)
• Appendix section:

44970 -- Laparoscopy, surgical, appendectomy

• Ureter section:

50715 -- Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis

• Vagina section:

57410 -- Pelvic examination under anesthesia (other than local)

• Oviduct/ovary section

58660 -- Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)

These bundles emphasize that +49327 is an add-on code for use with other codes in the same CPT® section.

"When indicated you will use + 49327 in conjunction with laparoscopic abdominal, pelvic, or retroperitoneal procedure(s) performed concurrently," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor at University Hospital, State University of New York, Stony Brook.

Pick correct catheter code: By bundling 49418 (Insertion of tunneled intraperitoneal catheter [e.g., dialysis, intraperitoneal chemotherapy instillation, management of ascites], complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous) with the following codes, CCI 18.2 ensures that you select the single, most-specific code to describe your surgeon's catheter placement:

• 49419 -- Insertion of tunneled intraperitoneal catheter, with subcutaneous port (i.e., totally implantable)
• 49324 -- Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter
• 49325 -- Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed
• 49400 -- Injection of air or contrast into peritoneal cavity (separate procedure)
• 49421 -- Insertion of tunneled intraperitoneal catheter for dialysis, open.