General Surgery Coding Alert

When complications occur during surgery, they often take extra time for the general surgeon to correct. But surgeons frequently dont know when or how to bill for that extra time. By using either modifier -22 (unusual procedural services) or -78 (return to the operating room for a related procedure during the postoperative period), surgeons can ensure they are reimbursed when complications arise.

Complications that are repaired during the original operative session should be billed by attaching modifier -22 to the primary procedure code. According to the national Correct Coding Initiative (CCI), general surgeons cannot bill separately for repairing complications that occurred during this procedure.

For example, during the course of a laparoscopic cholecystectomy (47563, laparoscopic cholecystectomy with cholangiography), a general surgeon lyses adhesions (44200, laparoscopy, surgical; enterolysis [freeing of intestinal adhesion][separate procedure]). During the course of the enterolysis, the surgeon notices a perforation of the small intestine that occurred during the lysis. He or she spends an additional 30 minutes repairing the perforation before proceeding with the cholecystectomy and cholangiogram.

Note: Surgeons should not bill lysis of adhesions with the cholecystectomy because the procedures are bundled. Also, please note that the CPT code for laparoscopic lysis of adhesions was changed to 44200 as of Jan. 1, 2000. The Health Care Financing Administration (HCFA) has established a grace period, however, until April 1, 2000, during which the old code, 56310, may be used.

No Separate Code

In this scenario, there is no separate code for repairing the complication that arose during the primary procedure. Consequently, the only way to get reimbursed for the extra time it took to lyse the adhesions and to repair the damage to the nicked bowel is to bill the laparoscopic cholecystectomy (47563) with modifier -22 attached.

The perforated bowel is not a mistake, but rather an unfortunate side effect of doing lysis of adhesions, says Terry Fletcher, BS, CPC, CCS-P, a coding and reimbursement specialist in Laguna Beach, Calif. Because a hole was inadvertently left in the bowel, it makes the procedure more complicated and longer to complete, so it is appropriate to bill for that extra time using modifier -22. If physician error causes the bowel perforation, the repair should not be billed, Fletcher adds.

Similar complications also may occur after the patient has left the operating room. For example, a woman may have a dermal inclusion or sebaceous cyst. When she sees a surgeon, he decides to remove it. The relatively routine procedure is complicated because the cyst is infected. Shortly after the procedure is completed, however, the woman returns because the wound is bleeding. The surgeon reopens the wound, fixes a blood vessel that was nicked inadvertently during the original surgery, and ties it off.

In this case, the repair could be billed with a modifier -78 attached because the complication arose after surgery and the patient was returned to the operating room.

Note: CCI states that an operative session ends as soon as the patient is released from the operating room.

Physicians Must Communicate With their Coders

If the complication is dealt with during the original operative session, only modifier -22 may be billed. Whereas if it is fixed later, the procedure may be billed with modifier -78. In either case, however, the real question often is: Does the physician even want to bill his patient (or the insurance company) for dealing with a complication arising from his or her own surgery?

Often, the answer is no, says Arlene Morrow, CPC, a coding and reimbursement specialist in Tampa, Fla. Somewhere in the documentation, the surgeon will have to define what the complication was, and many physicians are queasy about this. They may have strong feelings about billing for complications because they may imply that the surgeon made a mistake, even if they were unavoidable.

Although surgeons appropriately may code based on the documentation for the procedure, some feel guilty that a complication occurred and do not want to upset their patients by collecting a fee for what essentially was not a good outcome. Surgeons fear that doing so will spur malpractice complaints, Morrow says.

This is something physicians have to talk about with their coders. Otherwise, office staff may send out bills in the usual manner, even though the physician may not have wanted that particular bill sent out, Morrow explains. There needs to be open lines of communication to handle these delicate matters, and they should be discussed in advance.

M. Trayser Dunaway, MD, a general surgeon in Camden, S.C., and author of Pocket Guide to Clinical Coding, agrees. Surgeons are perfectionists, and whenever something happens that doesnt reflect that, we figure, It wasnt perfect, so Ill just go ahead and fix the problem, and I wont charge the patient.

Dunaway says that in this age of managed care when carriers often are billed instead of patients, surgeons need to change their ideas regarding billing for complications. He still thinks twice, however, before charging for a complication.

But Morrow notes that not billing for the complication doesnt necessarily end the matter. If the procedure was performed at a hospital or outpatient clinic, the facility is going to bill for it, and that bill wont be paid unless the carrier also receives a surgeons bill, she says. So surgeons may bring more attention to the matter by not billing.

She advises surgeons to seek counsel from the risk manager at the hospital concerning how to pursue such issues and then institute a policy.

Note: If the surgeon is called in to repair a bowel that was nicked by another physician, the repair should be billed using 44602 (suture of small intestine [enterorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture; single perforation); 44603 (multiple perforations); or 44604 (suture of large intestine [colorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture [single or multiple perforations]; without colostomy).