General Surgery Coding Alert

General surgeons may face difficulties getting reimbursed when they perform an appendectomy (44955) at the same time as another unrelated procedure. But they can bill for the appendectomy as a primary procedure as long as there is a documented problem with the appendix and the other procedure doesnt relate directly to the right colon.

Finding appendicitis in a patient during the course of another procedure is not a common occurrence. More frequently, a patient may have a bowel obstruction and appendicitisin fact, the appendicitis may be the cause of the bowel obstructionbut if the obstruction requires a right colectomy (44140, colectomy, partial; with anastomosis), the appendectomy cannot be billed because the appendix is simply an extension of the cecum at the bottom of the right colon and is removed along with the rest of the resected colon.

Insurance carriers, including Medicare also will not reimburse the removal of a healthy appendix. Surgeons often perform appendectomies (particularly on younger patients) during the course of more extensive abdominal procedures. Although taking out an appendix because it is there is not as popular as it was in the past, many surgeons still remove a healthy appendix simply because they have already opened the patient and removing the appendix eliminates a potential subsequent health problem.

To avoid paying for removal of healthy appendixes, many carriers now want to see proof (i.e., the operative report) that an appendectomy performed during the same session as another procedure was medically necessary, which means many first claims routinely are denied.

In the past, some doctors billed carriers for removing an appendix in the course of a right colectomy, whereas others took out the appendix routinely when performing abdominal surgery, whether it was medically necessary or not, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. She adds that most carriers will reimburse appendectomies if they are truly distinct procedures and are medically necessary.

Separate Diagnosis Required

The correct CPT code in these situations is 44955 (appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure][list separately in addition to code for primary procedure]). The key words in 44955s descriptor are indicated purpose, which means the appendectomy must be medically necessary (i.e., a diagnosis or sign or symptom). If the surgeon doesnt have a specific diagnosis before opening the patient, then signs or symptoms should be used. If the appendix returns from the pathology lab showing disease, that information also should be provided to the carrier, says Karen Evans, RN, CPC, an independent coding and reimbursement specialist in Mount Vernon, Wash.

If a patient has a gallbladder or ovarian problem, for example, and the surgeon finds appendicitis as well and performs an appendectomy, the physician should bill 44955 in addition to the primary procedure performed, as long as there is a separate diagnosis (i.e., appendicitis), sign or symptom or pathology that relates specifically to the appendix.

For example, a surgeon performs a diagnostic laparotomy to determine the source of a female patients abdominal pain and finds a ruptured ovarian cyst on the left and an inflamed appendix on the right. The surgeon then performs a left oophorectomy (58940, oophorectomy, partial or total, unilateral or bilateral) and also removes the appendix. When the pathology report returns, appendicitis is indicated. Therefore, the surgeon can bill for the appendectomy using 44955, Evans says, noting that if the pathology report had returned negative, the appendectomy shouldnt be billed.

Note: Code 44955 is a list in addition to or add- on code and therefore does not require modifier -51 (multiple procedures) and is not subject to multiple surgery discounts because its fee already is reduced.

Other Appendectomy Codes

CPT 2000 lists three other appendectomy codes:

44950appendectomy;
44960appendectomy; for ruptured appendix with abscess or generalized peritonitis; and
44970laparoscopy, surgical, appendectomy.

The first code, 44950, is used when the appendectomy is the only procedure performed. The surgeon opens the patient and finds that the appendix is inflamed but hasnt ruptured. If the same scenario unfolds laparoscopically, code 44970 should be used.

If the appendix has ruptured, 44960 is used unless a right colectomy is required. In that case, the colectomy would be charged instead, Evans says. If no colectomy is performed, 44970 includes both the removal of the ruptured appendix and debridement and lavage of the area to make sure all infected tissue and fluid is removed. In this situation, Evans says, diagnosis codes relating both to the appendectomy (appendicitis) and debridement and lavage (peritonitis) should be included.