Reader Question:
Denial of Two Procedures Due to Unbundling
Published on Thu Jul 01, 1999
Question: Recently, one of our female patients was scheduled for a hemicolectomy. When the surgical team went in they found an incarcerated ventral hernia and peritoneal lesions. We billed 44140-22 for the hemicolectomy, as well as 49561-51 for the repair of the initial ventral hernia, and 44005-51 for the lesions. HCFA denied the latter two procedures. Why?
Rosemary Pagan, Coder
Campisi Harold & Hart, Orlando
Answer: The claim was denied because the three procedures claimed above are bundled. In the April 1999 edition of the Medicare Update for the National Correct Coding Initiative and Payment Manual, 49561 is bundled into 44140 (colectomy, partial) -- unless the hernia in question is outside of the incision made for the hemicolectomy.
Arlene Morrow, CPC, CMM, says that in most abdominal surgeries, Medicare and commercial insurance carriers will assume that hernia repair, appendectomy and lysis of adhesions are incidental services and not payable separately.
The regulations on reimbursement and bundling of these services are very payer-specific and often will require an appeal with request for peer review by a board-certified surgeon in the same specialty.
Morrow adds that excellent documentation in the operative medical record is essential for a successful appeal.
Rita Scichilone, MHSA, RRA, CCS-P, a manager in the coding products and services division of the American Health Information Management Association (AHIMA), says it is worthwhile to appeal, as about 80 percent of appeals are won.
There are several coding options for the example above depending upon the specifics of the payer. The 44140 (hemicolectomy) would be considered the primary procedure (and it was paid). The 44005 (enterolysis) is listed as a separate procedure, whereas by definition it is considered a component of a more complex service and not usually identified separately.
If it is performed alone and for a specific and documented purpose (i.e., a different diagnosis, such as bowel obstruction), it may be reported separately with a -59 modifier (distinct procedure).
Modifier -59 is used to identify procedures that are normally not reported together, but are appropriate under normal circumstances. Even though the procedures are bundled, the -59 may cause the edit to drop and you to be reimbursed. But be warned, continually utilizing modifier -59 is a red flag for medical review.
When the diagnoses are the same, if there is good documentation in the operative note to demonstrate the unusual difficulty, Morrow recommends reporting the 44140 (hemicolectomy) with -22 modifier with a cover letter requesting additional reimbursement based on the percentage of additional difficulty. Comparing the procedures degree of difficulty to the average for such procedures would also be helpful.
Coding 49561 (ventral hernia repair) is considered incidental in Medicares National Correct Coding Initiative, as well as by commercial carriers.
