General Surgery Coding Alert

Forget these coding tools and lose pay.

Now that you’ve tried your hand at coding the five scenarios above, here is your opportunity to see how you did.

We had our experts look at these cases and provide you with the best modifier tips to make sure you get all the pay you deserve for your surgeons’ work.

Compare Expert Answers to Your Modifier Choices

Answer 1: Since this visit does not constitute postoperative follow up examination or care of a recent surgical wound but rather a visit to evaluate a separate condition, you can report the E/M service with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period).

Tip: Before considering modifier 24, ensure that the same physician who performed the original surgical procedure or one of his associates sees the patient during the postoperative period for an E/M service unrelated to the postoperative surgical care.

Answer 2: Even though the first patient encounter was in the ER, you should not use one of the codes from the range 99281-99285 (Emergency department visit …). Because the surgeon admitted the patient the same day, you’ll need to report a single E/M code for initial hospital inpatient services for the day.

Do this: Choose the appropriate code from the range 99221-99223 (Initial hospital care …) based on the level of history, examination, and medical decision making (HEM). You should base the HEM level on all the encounters with the patient during the day (except for the surgery), including the ER encounter. You can append modifier 57 (Decision for surgery) and additionally report the surgery with 44950 (Appendectomy) in this situation.

Reminder: When the provider performs an E/M service for a patient that leads to surgery that day, you’ll likely append modifier 57 to the E/M code, relays Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Never append modifier 57 to a procedure code; it’s for E/Ms only, and only in specific circumstances.

Answer 3: Yes, you need a modifier to report together the following two procedure codes:

• 19302 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy)
• 19083 (Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance).

CMS’s National Correct Coding Initiative (CCI) bundles these in the procedure-to-procedure edits, identifying 19083 as a component of the more-extensive procedure 19302.

In other words, if you don’t use a modifier, the payer will assume that the surgeon performed a biopsy, and finding more extensive disease, did a lumpectomy on the same breast.

CCI lists 19302 and 19083 with a modifier-indicator of “1,” meaning that you can override the edit pair by appending the appropriate modifier if you meet the following criteria, according to CMS:

“Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

Because the surgeon performs these procedures at different anatomic sites, the answer to your question is as simple as applying modifier 59 (Distinct procedural service) to 19083 (the column 2 code).

Tip: Depending on your payer policies, you may want to consider the use of the X{EPSU} modifier set in place of modifier 59. Modifier XS (Separate structure), for instance, is specifically designated to distinguish services performed at different anatomic sites on the same day.

Answer 4: Enterolysis is built into the fee schedule for abdominal procedures such as laparoscopic colectomy, but you do have an option to possibly capture additional pay for a difficult case. If your surgeon documents extensive cutdown of adhesions that requires additional resources and time beyond the normal work involved in the procedure, you may turn to modifier 22 (Increased procedural services) to document and perhaps get paid for the additional work.

In this case, you might append modifier 22 to the procedure code 44204 (Laparoscopy, surgical; colectomy, partial, with anastomosis).

Important: A diagnosis alone does not support the medical necessity of reporting modifier 22. The documentation must clearly indicate that the procedure was more complex than normal, and detail why, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh.

For instance: The payer will want to see the extra work clearly quantified by time or percentage, since they will be paying a set increased percentage for any modifier-22 procedure.

Answer 5: You would report the lesion excision as 11402 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm) linked to L72.3 (Sebaceous cyst).

You should also report the visit code (9921X) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Remember: Since the surgeon provided a separate and significant E/M service at the same time as a minor procedure, modifier 25 is the best choice. Modifier 25 should not signify the decision to do a minor surgery at the time of the visit, which is integral to that minor surgery, but rather that the physician documented a separate significant E/M service. Appropriately appending modifier 25 means that your practice will receive a separate payment for an E/M service that the surgeon performed on the same day as a procedure or other service.

In fact, if the patient reports for any unrelated E/M that occurs during a postop global period — including hospital visits, office visits, etc. — you may append modifier 24, according to Celia Forde, CPC, CPCH, coding specialist for Florida’s Central Care, in the Orlando area.