General Surgery Coding Alert

Check the site before you use modifier 22.

If you follow the coding lore that tells you to never separately code lysis of adhesions with another surgery, you could cost your practice hundreds of dollars in some cases.

Beware: It’s true that separately reporting adhesiolysis is often prohibited, but even then you have some options to get paid for the extra work.

Do this: Follow our experts’ tips to learn when and how to capture extensive lysis of adhesions and get all the pay you deserve.

Tip 1: Bundle Adhesiolysis — Usually

Adhesions are bands of fibrous scar tissue that may form in the abdomen and pelvis after surgery or due to infection. Because adhesions connect organs and tissue that are normally separated, they can lead to a variety of complications, including abdominal or pelvic pain, bowel obstruction, and infertility. Adhesions commonly form on the intestines, ovaries, and pelvic sidewalls.

General surgeons are most likely to encounter lysis of adhesions in the abdominal and possibly pelvic region, represented by the following CPT^® codes:

• 44005, Enterolysis (freeing of intestinal adhesion) (separate procedure)
• 44180, Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)
• 58660, Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
• 58740, Lysis of adhesions (salpingolysis, ovariolysis).

Bundled: If your surgeon performs any other surgical procedure in the same surgical field as the lysis of adhesions, you should not separately report one of the preceding adhesiolysis codes. That’s because a primary procedure code includes the service of a CPT^® “separate procedure” code when it’s part of the primary procedure. So when a surgeon cuts through adhesions to access the surgical site, you should bill just the primary surgical code.

That’s also why you’ll see Correct Coding Initiative (CCI) edit pairs for most abdominal surgeries with 44005 and 44180, and for most pelvic surgeries with 58660 and 58740.

Exception: You might be able to charge for adhesiolysis at the same session as the surgeon performs another procedure in one of the two following situations:

• the lysis of adhesions is extensive, or
• the adhesiolysis is at a different anatomic site using a different approach from the main procedure(s).

Tip 2: Consider Modifier 22

If the lysis of adhesions is extensive and the CCI or other bundling software includes this extensive service in the primary procedure, you should add modifier 22 (Increased procedural services) to the primary procedure code, says Dorine Marshall, CPC, biller at OSU Physicians in Tulsa, Ok.

Caution: You should use modifier 22 only rarely, not for every case with adhesions that is a little harder than average. Before you use the modifier, you should have supporting documentation that details the physician’s extensive time and work effort. Modifier 22 will almost certainly initiate a request for information from your payers, so make sure the operative report substantiates the claim.

Documentation must describe the difficult conditions, such as dense, adherent adhesions with blood supply, as well as the significant work associated with the removal, such as using sharp dissection and sometimes laser. You should also make a statement about the time spent in adhesiolysis beyond the normal procedure time.

Beware conversion: Sometimes a surgeon attempts a procedure laparoscopically, but because of extensive adhesions, must change to an open approach to complete the surgery. In this case, Medicare rules — and those of the many payers that follow Medicare — bundle the laparoscopy into the open procedure, so you can’t report it separately. In those cases, the only option to capture the adhesiolysis work is to report the converted open procedure as the primary surgery, and append modifier 22 (with documentation) for the additional work.

Estimate cost: When you submit a claim with modifier 22, you should include an estimate of what you expect as compensation for the extra work involved in the procedure. Otherwise, you are leaving the decision up to the payers, and they will potentially base your reimbursement on their standard allowable.

Tip 3: Differentiate Site, Approach

Establishing where the surgeon lysed the adhesions is the next major step to determine which code to select. If the surgeon performed adhesiolysis of the bowel, you would report 44005 or 44180, if appropriate, depending on the approach, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

If the physician lysed pelvic adhesions, you should submit 58660 or 58740, if appropriate, depending on the adhesions’ exact location, she adds.

Although CCI bundles most abdominal and pelvic surgeries with most lysis of adhesions codes, there are unusual circumstances when the surgeon uses a different approach at a different surgical site. In those cases, you can bill both procedures using appropriate CPT^® codes.

For example: For patient complaining of left lower quadrant pain, ultrasound showed left ovarian entanglement, and the surgeon performed laparoscopic procedure, finding extensive ovarian adhesions that he had to take down. Surgeon noted inflammation of a retrocaecal appendix, and proceeded to an open appendectomy due to poor visualization of the site.

Code this: You should report the open appendectomy as 44950 (Appendectomy). Because the lysis of adhesions was at a different site using a different surgical approach, you can also bill 58660 for the laparoscopic ovariolysis. If you failed to separately bill this work based on the assumption that you must always bundle adhesiolysis, you would lose $688.35 (Medicare Physician Fee Schedule national facility amount, conversion factor 35.8887).

Caveat: Always check CCI edits before billing adhesiolysis on the same date as any other procedure. You’ll find edit pairs that restrict reporting most abdominal or pelvic codes with a separate code for lysis of adhesions, and the edit pairs typically shows a modifier indicator of “0,” meaning that you cannot unbundle these codes using a modifier such as 59 (Distinct procedural service).