General Surgery Coding Alert

You can report diagnostic scope separately -- in some cases If you follow a few simple rules, you-ll find that reporting thoracoscopy procedures is a cinch. Let our experts share with you the facts you need to guarantee success on every thoracoscopy claim. 1. Report Truly -Diagnostic- Scope Separately If the surgeon performs a diagnostic thoracoscopy (32601-32606) and, as a direct result of her findings, determines the need for an open surgical procedure, you may report the diagnostic thoracoscopy separately. CMS guidelines, as outlined in the national Correct Coding Initiative (CCI), specifically state that if the surgeon performs an endoscopy for an initial diagnosis on the same day as the open procedure, you may report the endoscopy separately. Apply a modifier: For Medicare payers, you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the open procedure to indicate that the diagnostic endoscopy and the open surgical service are staged or planned procedures, according to instructions in CCI's introduction (section C, #12). In addition, "the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy," CCI says. Example: The surgeon uses diagnostic thoracoscopy to examine a patient with pain and breathing difficulty (32601, Thoracoscopy, diagnostic [separate procedure]; lungs and pleural space, without biopsy). The surgeon identifies and locates a foreign body in the pleural space, and removes the object via thoracotomy (32150, Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit). In this case, because the scope determined the need for the thoracotomy, you should claim both 32601 and 32150-58. Don't overdo it: If the surgeon uses a diagnostic scope to "scout" the surgical field -- to establish anatomic landmarks or to discern the extent of disease -- you cannot report the diagnostic scope separately, says M. Trayser Dunaway, MD, a surgeon, speaker, coding educator and healthcare consultant in Camden, S.C. Rather, the diagnostic scope must lead directly to the decision to perform surgery. 2. Never Separate Diagnostic and Surgical Scopes When the surgeon performs a diagnostic thoracoscopy followed by a surgical thoracoscopy (32650-32665), you may report only the surgical thoracoscopy, regardless of whether the results of the diagnostic scope prompted the surgical scope, says Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C. As CPT instructions clearly state, "Surgical thoracoscopy always includes diagnostic thoracoscopy." Example: Returning to the above instance of foreign-body removal from the pleural space: If, instead of thoracotomy, the surgeon removes the object via thoracoscopy (e.g., 32653, Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit), you would not report the diagnostic thoracoscopy (32601) separately. Rather, because surgical scope always includes diagnostic scope, you would [...]