General Surgery Coding Alert

A lot of attention is paid to in addition to codes and separate procedures, but there is another, far lesser known kind of CPT code that restricts utilization to a specific diagnosis. And the consequences of misusing these codes can be dire, according to Georgeann Edford, RN, MBA, who heads Coding Compliance Solutions, a medical reimbursement firm in Birmingham, MI.

Edford calls this group of codes for procedures, because each can only be used for a specific diagnosis listed in CPT 1999. Some examples of CPT codes relating to general surgery in this category are:

43846, gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [less than 100 cm] Roux-en-Y gastroenterostomy.

44015, tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method [List separately in addition to primary procedure]

44615, intestinal stricturoplasty [enterotomy and enterorrhaphy] with or without dilation, for intestinal obstruction

44960, appendectomy; for ruptured appendix with abscess or generalized peritonitis.

45500, proctoplasty; for stenosis

45505, proctoplasty; for prolapse of mucous membrane

45540, proctopexy for prolapse; abdominal approach.

When you use these for codes, it must be for the diagnosis listed in the CPT book, Edford says. If the code is for another diagnosis, then youre using it for the wrong reason.

Note: The procedures are restricted to a specific diagnosis, not a specific primary procedure.

The restrictions on these codes mean that using the correct diagnosis code is critical to get paid. Of course, diagnosis codes are always required when billing to show medical necessity. But with these codes, medical necessity is taken to a stricter level, as only one specific diagnosis will do.

Although these codes has never been systematically categorized in the CPT manual the same way as separate procedures or list in addition to codesthose codes are listed with brackets in the CPT book, for instance, whereas the word for is not emphasized and can easily be overlooked or its strict meaning misunderstoodutilizing them incorrectly can result in stiff sanctions for surgeons.

Edford says the misuse of these codes is a major area of fraud and abuse. If physicians use these codes for a different diagnosis, Medicare may view it as intentional fraud if they do an audit, she says. Misuse may also be construed as unbundling, Edford warns.

Some physicians will use these codes even though there is a different diagnosis so they can bill for the service, even though it is bundled into the primary procedure, Edford says.

However, there can be a severe price to pay for such incorrect coding, because Medicare may view the error as deliberate. When there is intentional disregard of coding rules, she says, thats when you get into big trouble, citing one case where the misuse of a for code [...]