General Surgery Coding Alert

Include venous access, radiology in many procedures.

You’re facing the last annual update before CPT® 2015 goes into effect, but Medicare’s Correct Coding Initiative (CCI) shows no sign of letting up on restrictions for your general surgery practice. 

CCI version 20.3 boasts 5,247 new edit pairs, bringing the total to number of active edits to 1,340,210, according to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. in his analysis of the update.

The latest version went into effect Oct. 1, so read on, because we have the low down on edit pairs you need to know for your practice. 

Heed ‘Separate Procedure’ Advice

Medicare creates more than 50 new edit pairs for procedures that your general surgeon might perform based on the CPT® “separate procedure” definition, according to the edit table. 

Specifically: CCI 20.3 bundles 49400 (Injection of air or contrast into peritoneal cavity [separate procedure]) as a column 2 code with a host of laparoscopic procedures in the following code ranges, with abbreviated descriptions:

• 38120 — Laparoscopic splenectomy
• 38570-38573 — Laparoscopic lymph node excisions
• 43279-43283 — Laparoscopic esophageal procedures
• 43644-46353 — Laparoscopic stomach procedures
• 43770-43775 — Laparoscopic bariatric surgery
• 44180-44227 — Laparoscopic intestinal procedures 
• 45395-45402 — Laparoscopic rectum procedures
• 47370-47371 — Laparoscopic liver procedures
• 47560-47570 — Laparoscopic biliary tract procedures
• 49320-49327 — Laparoscopic peritoneal procedures
• 49650-49657 — Laparoscopic hernia repair.

Understand ‘separate procedure’: “When a CPT® code includes a parenthetic note stating ‘separate procedure,’ you shouldn’t report it with another code for a procedure that typically includes the ‘separate procedure’ as a standard part,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

“If the surgeon performs the procedure during the same operative session at the same site as a primary procedure, you should not report a ‘separate procedure’ code, because the primary procedure includes the service,” Bucknam says. “You can bill ‘separate procedures’ with other procedures, but it usually involves a procedure on another part of the body.”

With that logic in mind, you can see that if your surgeon injects air or contrast into the peritoneal cavity as part of any of the listed laparoscopic procedures, you should not separately bill for the air or contrast. “In fact, injecting air or contrast into the peritoneum is a typical step that is part of most laparoscopic procedures,” Bucknam says.

No override: CCI 20.3 lists each of the preceding edit pairs with modifier indicator “0,” which means that you cannot override the edit pair under any circumstances. 

Include Radiology, Catheter Procedures

CCI 20.3 also adds edit pairs to limit separate billing of radiology and vascular access procedures in addition to a primary surgical code.

In particular: You’ll see a host of new edit pairs with the following three codes for procedures that your surgeon might perform:

• 37241 — Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
  
• 37242 — … arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)
  
• 37243 — … for tumors, organ ischemia, or infarction.
  

CCI 20.3 lists the preceding three codes as a column 1 code with a host of column 2 codes, such as some codes in the following ranges, with abbreviated descriptions:

• 36005 — Injection procedure for extremity venography 
• 36010-36013 — Introduction of catheter
• 36100-36140 — Introduction of needle or intracatheter
• 36215-36254 — Selective or non-selective catheter placement.

“These edits support a change happening throughout CPT® to include the radiology and vascular access procedures as part of the primary procedure code, rather than billing separately for them,” Bucknam says.

Prepare for Modifier Changes

New edit pairs are not the only changes you need to master when CCI updates the edit file. You should also watch out for changes in the modifier indicator status that can impact how you report services your surgeon performs.

In CCI 20.3, “There were 248 changes to the modifier indicators, with all but one going from ‘1’ (you may be able to bypass using a modifier) to a ‘0’ (a modifier is never appropriate),” Cohen says. 

Of that number, nearly 30 modifier changes could impact your surgery coding. All of those involve a modifier indicator change from “1” to “0” for edit pairs with 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) and 49010 (Exploration, retroperitoneal area with or without biopsy[s] [separate procedure]).

Here are some of the bundled column 1 codes that your surgeon might perform (with abbreviated descriptions) with column 2 codes 49000-49010:

• 38794 — Thoracic duct cannulation 
• 43415 — Esophageal suture, transthoracic or transabdominal
• 43845 — Biliopancreatic diversion with duodenal switch
• 43881-43882 — Open neurostimulator electrode placement, revision, or removal
• 44158 — Total abdominal colectomy with proctectomy and ileal reservoir
• 44312 — Simple ileostomy revision 
• 44340 — Simple colostomy revision
• 45126 — Pelvic exenteration with proctectomy and removals such as bladder, ureter, uterus, cervix, tubes and ovaries
• 46712 — Ileoanal pouch repair transperineal or transabdominal
• 48550 — Donor pancreatectomy for transplantation
• 49002 — Reopen recent laparotomy
• 49324-49325 — Surgical laparoscopy with intraperitoneal catheter insertion or revision 
• 49405 — Image guided catheter drainage
• 49904 — Omental flap for defect repair.

Don’t forget: “The ‘0’ modifier indicator means that you should not use a modifier to override the edit pair under any circumstances,” Bucknam says.

Learn related new edits: CCI 20.3 also bundles 11402-11403 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs;…) as column 2 codes with 49000. Unlike the modifier revisions, however, these edit pairs have a modifier indicator of “1.”