General Surgery Coding Alert

Modifiers can't save you from these bundling edits

You can forget about separate reimbursement for mesh placement during a number of hernia repair procedures. Version 11.3 of the National Correct Coding Initiative bundles add-on code 49568 to 49570-49651, and you won't be able to override these edits with any modifier.

Edits reinforce clinical practice: If you-re coding correctly now, the effects of the mesh placement bundling edits shouldn't trouble you. That's because, as designed by the AMA, +49568 (Implantation of mesh or other prosthesis for incisional or ventral hernia repair) applies to incisional and ventral hernia repairs only, while 49570-49651 describe epigastric, umbilical, spigelian and inguinal hernia repairs.

-Placing mesh takes more time and increases the risk of infection,- but it isn't necessary in most cases, says M. Trayser Dunaway, MD, FACS, a general surgeon in Camden, S.C. -I guess there are some surgeons who might use mesh more often if they were paid more for it- with 49570-49651. But now, -insurers simply pay for a -hernia repair- and leave it up to the surgeon to choose if he-ll use mesh,- Dunaway says.

Include Esophagoscopy in Upper GI Scope

In the rare case that your surgeon would perform esophagoscopy as described by 43202-43232, you should not report the procedures in addition to upper GI endoscopy 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing). NCCI now bundles 43202-43232 to 43235 and will not allow for separate billing using modifier 59 (Distinct procedural service) or any other modifier.

-This edit extends the prior edit of 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) with 43235 to include all esophagoscopy therapeutic codes,- says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. -There are now no therapeutic procedures unique to the esophagoscopy codes that cannot be described in an endoscopy code (43235-43255).- The edits should have no negative effects because they only reinforce standard billing conventions for upper endoscope procedures, Weinstein adds.

Now's the time: NCCI 11.3 was effective Oct. 1.