General Surgery Coding Alert
Fine Needle Aspiration Edits Top List of Latest Coding Initiative Changes
Many of the new surgical edits should not have a significant impact on how practices bill for their services, because the procedures involved should not have been billed separately all along. A sigmoidoscopy, for example, has long been considered bundled if performed during the same session as a colonoscopy, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.
"Surgeons should remember that not all edits are in the CCI," she says. "There are many principles, conventions and policies that govern procedural coding, all of which can determine whether procedures may be billed separately when performed together."
However, Mueller says, "Physicians who are unfamiliar with the guidelines continue to bill separately for such procedures." As a result, formal edits may be introduced in the CCI to stop the practice.
The introduction of CPT codes generates CCI edits that follow existing coding conventions, Mueller says. The introduction of 45136 (excision of ileoanal reservoir with ileostomy) in CPT 2002, for example, generated a comprehensive/component edit involving 45136 and 44005 (enterolysis [freeing of intestinal adhesion][separate procedure]) that accounts for the fact that 44005 is a separate procedure, i.e., a procedure that can only be reported when it is performed on its own and may not be billed when performed in conjunction with a primary procedure.
Note: Even if there is no CCI edit, lysis of adhesions (whether open or laparoscopic) performed during another procedure should not be reported separately.
Fine Needle Aspiration
CPT 2002 introduced 10021 (fine needle aspiration; without imagining guidance) and 10022 ( with imaging guidance) for reporting FNA biopsies, noting that codes previously used to report this procedure (88170 and 88171) have been deleted. CCI 8.0 bundles 10021 and 10022 with 19290 (preoperative placement of needle localization wire, breast), as well as with codes for breast excisions (19110-19125, 19140-19200 and 19240), deep or superficial muscle biopsies (20200-20206), pneumocentesis (32400-32420), salivary gland biopsies (42400) and thyroid excisions (60001).
Even more codes would likely bundle with 10021 and 10022 were it not for what appears to be a computer glitch or other error, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C.
Although CPT 2002 says 88170 (fine needle aspiration; superficial tissue [e.g., thyroid, breast, prostate]) and 88171 ( deep tissue under radiologic guidance) have been deleted, Callaway says CCI 8.0 bundles 88170 and 88171 with breast biopsy codes 19100-19103.
She hopes the error will be corrected in CCI 8.1, but Callaway advises that "the edits should still be applied. That means 10021 or 10022 should not be billed with needle core or incisional breast biopsies."
All FNA edits bear a "1" indicator, which means the edit may be bypassed in certain situations. For example, if an incisional biopsy is performed on the left breast and the surgeon performs an FNA on the right breast or at a different site on the left breast, both biopsies may be reported with modifier -59 (distinct procedural service) appended to the appropriate FNA code (the lesser-valued procedure).
Endoscopic Procedures
Many CCI 8.0 edits center on endoscopic procedures:
The CCI says these edits invoke the "most extensive procedure" guideline, which states that "when procedures are performed together that are basically the same, or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure."
It should be remembered that these guidelines have existed for years and that neither coding specialists nor carriers recommend reporting two such scopes separately.
"There seem to be a lot of omissions in the edits," Mueller says. "In some cases, codes seem to be bundled with one procedure but not another, even though there is no substantive difference between the two in relation to the code being bundled." In such cases, other coding policies (including the recently revised guidelines in CCI/Chapter One) should be consulted before the two codes are billed together. Depending on the circumstances, it may be inappropriate to bill the services separately, even in the absence of CCI edits.
Note: Due to the large number of edits involving these endoscopic codes, the complete list cannot be broken out in full. If your practice subscribes to the CCI, make sure you consult CCI 8.0 before reporting multiple endoscopic procedures. All the coding specialists contacted for this issue strongly recommend that practices subscribe to the CCI quarterly to obtain the most current bundling information.
Deleted Edits
A laparoscopic enterectomy performed in conjunction with an open partial colectomy could not be reported separately before 2002 because the descriptor for 44202 that appeared in CPT 2001 could have applied to either the large or the small intestine. The descriptor was reworded for CPT 2002, clarifying that 44202 (laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis) refers specifically to the small intestine and can no longer be considered a component of the resection of the large intestine. CCI 8.0 has deleted the 44202 edit and replaced it with partial colectomy codes 44140-44147.
Mueller says the Medicare guideline that a laparoscopic procedure converted to open procedure should only be billed for the open procedure does not apply in this situation because the surgeon probably determined the need for the open colectomy only during the course of the laparoscopic enterectomy. If the colectomy was performed first, however, the laparoscopic enterectomy could not be billed (and probably would not be performed, because the patient has already been opened).
General Surgery Coding Alert
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