General Surgery Coding Alert

Although many new code combinations have been added with version 8.1 of the Correct Coding Initiative (CCI) that involve general surgery procedures, virtually all reinforce already-existing coding protocols (such as bundling CPT-designated "separate procedures" with more extensive related codes) and should not affect billing or revenue significantly.

Most of the edits are proactive rather than reactive, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist in Eau Claire, Wis. "For the first few years, the CCI reacted, trying to correct errors. With most of those edits out of the way, they seem to be turning their attention to proactive edits that are consistent with AMA/CPT guidelines."

The edits should clear up any confusion regarding whether two services are automatically billable if there is no edit in the CCI. "Just because there isn't an edit does not mean you can bill the two services together," Rasmussen says.

For example, 38500 (Biopsy or excision of lymph node[s]; open, superficial) now is bundled with lymphadenectomy codes 38700-38747, which is consistent with Medicare guidelines that include such biopsies in more extensive excisions.

The edit has a "1" indicator, however, which means it may be bypassed with a modifier when appropriate. If the biopsy was diagnostic and led to the decision to perform the lymphadenectomy, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) should be appended to the appropriate lymphadenectomy code to indicate the procedure was preplanned (if the biopsy returned positive).

Note: In version 7.3 (October-December 2001), Medicare revised the CCI guidelines in Chapter 1 concerning diagnostic endoscopies (and, by extension, diagnostic biopsies). Prior to version 7.3, surgeons were not instructed to use modifier -58; instead, they were required to append modifier -59 (Distinct procedural service) to the diagnostic procedure code. Some carriers still may require modifier -59 in such cases.

Other edits that validate existing correct coding practices include:

Debridement With Complex Repairs. Debridement codes 11000-11044 now are bundled with complex repairs (13100-13152). Debridements normally are part of wound repair, notes Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. She notes that the definition of complex repair of the CPT manual states: "Necessary preparation includes creation of a defect for repairs ... or the debridement of complicated lacerations or avulsions " Therefore, Cobuzzi says, "it makes sense that CCI now bundles debridements with these procedures."

Fine Needle Aspiration With More Extensive Biopsies. CPT 2002 introduced two new fine needle aspiration (FNA) codes: 10021 (Fine needle aspiration; without imaging guidance) and 10022 ( with imaging guidance). Both codes now are bundled with many more extensive biopsy procedure codes.

Esophagoscopy for Biopsy With Other Esophagoscopy Codes. Code 43202 (Esophagoscopy, rigid or flexible; with biopsy, single or multiple) is bundled with 43216 ( with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) and 43217 ( by snare technique). The simpler endoscopic biopsy is included in a more extensive endoscopic excision.

Most of these edits have a "1" indicator, meaning they may be bypassed with the appropriate modifier if the procedures are performed at different times during the day or at different anatomic sites.

Note: When two esophagoscopies, such as 43202 and 43216, are performed on different parts of the esophagus, they may be reported separately (with modifier -59 appended to 43202). Because both codes are in the same endoscopic "family," multiple-procedure rules do not apply. Instead, the services are subject to the multiple-endoscopy rule, which means the fee for the "base" endoscopy for that family (in this case 43200) is subtracted from the fee for the lesser procedure (43202). The more extensive procedure should be paid at 100 percent.

Abdominal Aortic Aneurysm Codes. Codes 34812 (Open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral), +34813 (Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair [list separately in addition to code for primary procedure]) and 34820 (Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral) have been bundled with more than 75 codes each.

Many of these edits include other procedures involving the femoral or iliac arteries, Rasmussen notes. "The reason they probably bundled this is that many coders do not read the entire description of the codes, which were designed specifically to be used with other endovascular repair AAA codes only," she says. "This is obvious if the full code descriptor is read. But some billing software only permits a few words, so the descriptor might read 'femoral artery exposure.' It's another example of why it's so important to read code descriptors in the CPT manual."

Colonoscopy Screening Bundles E/M Services. By definition, a patient who will have a screening colonoscopy should not have a chief complaint. Without a chief complaint, an E/M service cannot be charged. This is now reflected in the CCI, where G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) bundles most E/M visit codes.

Note: To find out about other edits not mentioned in this article or to obtain other information, you can subscribe to the CCI by contacting the National Technical Information Service through its Web site www.ntis.gov.