General Surgery Coding Alert

Then check your answers to hone coding skills.

If your general surgeon's op report goes slightly off-script for common gastro-intestinal (GI) or abdominal surgeries, do you how to get the coding right?

Study the following scenarios, then try your hand at the answers. Make sure to look for cases that fall short of the standard CPT® descriptor or document additional services, and adjust your coding accordingly.

Case 1. Identify the 'Reason for the Test'

A 66-year-old Medicare patient presents for a colonoscopy. She has no symptoms and has never had a screening colonoscopy before.

The patient is anesthetized and is positioned in the left lateral decubitus position. During rectal exam, sphincter tone appears normal and no masses are observed. When the colonoscope is introduced into the rectum and advanced to the distal sigmoid colon, a benign appearing sessile polyp is seen in the sigmoid colon, which is measured to be 6 mm in size. I removed and retrieved the polyp using hot biopsy forceps, and monitored blood loss, which was minimal.

Choose your coding:

     A. G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
     B. 45384-PT (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)-(Colorectal cancer screening test converted to diagnostic test or other procedure)
     C. 45385-PT (... with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)-(Colorectal cancer screening test converted to diagnostic test or other procedure)
     D. 45384-33 ... (Preventive services)

Answer: Although G0121 would be the correct code for this case if the surgeon hadn't removed a tissue specimen, the surgeon's action changes the case from a screening to a diagnostic colonoscopy. When that happens, you can no longer use the screening procedure code, so choice (A) is off the table.

The correct procedure code for this case is 45384. That's because the surgeon documented removing the polyp by hot biopsy forceps, not by snare technique, eliminating 45385 (C) as an option.

Complication: This procedure was originally a screening colonoscopy that turned diagnostic on the basis of findings. You need to communicate that fact to your payer, because it has major implications for whether the patient is on the hook for co-pays and deductibles for the procedure.

Because the payer in this case is Medicare, you should report the procedure code with modifier PT, making the correct answer choice (B), not (D). For many non-Medicare payers, you might use modifier 33 instead - but check with your payers to be sure.

Case 2. Focus on Service Documentation

A 72-year-old male patient presents with fluid accumulation in his abdomen. After preparation of the abdominal tap kit, the surgeon reconfirmed the border of the ascites and identified a suitable site for paracentesis. After percussion to reconfirm the border, the tap site was marked in the midline 2, cm under the umbilicus. A betadine swab was used to clean the area and the area was then isolated using a sterile drape. The syringe was loaded with the local anesthetic and it was penetrated into the skin at a 90-degree angle while the left hand stabilized the area of penetration.

The anesthetic was then slowly injected into the area with alternate aspiration and injection. I made a slight cut using a number 11 scalpel blade to permit catheter passage, then prepared the flexible catheter and used a large needle to enter the peritoneal space. Negative pressure was applied to help ascertain the location into the peritoneal cavity. The needle was positioned 3 cm into the peritoneal cavity to avoid displacement.

The needle was then held in place with one hand and the catheter was slowly advanced all the way over the needle. Once the catheter was in place, the needle was slowly removed. A large syringe was then attached to the stopcock. Using slow aspiration, the fluid was then collected in the syringe and stored in the vial to be sent to the laboratory for diagnosis.

Choose your coding:

     A. 49062 (Drainage of extraperitoneal lymphocele to peritoneal cavity, open)
     B. 49082 (Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance)
     C. 49083 (... with imaging guidance)
     D. 49084 (Peritoneal lavage, including imaging guidance, when performed)

Answer: You can eliminate choice (A), because the op note does not document a lymphocele. In addition, the procedure described is an open operation, and the doctor performed paracentesis rather than drainage, says Glenn Littenberg MD, a physician in Pasadena, Calif. You can also eliminate choice (D) for not describing a paracentesis procedure.

The correct answer is (B), 49082, because the code describes the surgeon's work performing the paracentesis. You may be used to reaching for 49083 for paracentesis cases, but because there's no documentation of imaging guidance, choice (C) is also the wrong code.

Case 3. Scrutinize Specimen Collection

A 73-year-old male patient presents for an EGD procedure. The patient was sedated and placed in the left lateral decubitus position. I inserted a video endoscope via the oropharynx and advanced it to the descending portion of the duodenum without difficulty, where I found a healthy duodenum. I withdrew the scope to the stomach, where gastroscopy revealed no defects. Retroflexion views revealed a hiatal hernia of significant size. I readjusted the scope to the proximal gastric body where the hiatal hernia was measured to be appx. 10 cm in size.

Several Cameron lesions were noted in the distal portion of the hiatal hernia sac, but I did not observe any bleeding. I withdrew the scope through the esophagus, where the esophageal mucosa appeared tortuous. No complications were noted during the procedure, which the patient tolerated well.

Choose your coding:

     A. 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
     B. 43236 (... with directed submucosal injection(s), any substance)
     C. 43237 (... with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)
     D. 43238 (... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures))

Answer: The op note doesn't document ultrasound examinations, which eliminates choices (C) and (D). Nor does the note document injections, eliminating choice (B).

That leaves choice (A) as the correct answer, but many coders are thrown off by the "including collection of specimens" statement, because the op note also doesn't document specimen collection.

Look closely: The 43235 code definition goes on to state, "when performed," meaning that specimen collection isn't required for you to use this code. The correct choice for this case is (A).