General Surgery Coding Alert

Read the operative note carefully and apply modifier -22 when justified

If you're not reading the surgeon's operative notes for laparoscopic cholecystectomy (lap chole) carefully, you could be missing billable services such as cholangiography or lysis of adhesions and leaving dollars on the table. At the same time, you must avoid overcoding laparoscopic-to-open conversions by claiming only the successful procedure.

Step 1: Determine EVERYTHING the Surgeon Did

 When coding for lap chole (laparoscopic removal of the gallbladder), you should  carefully read the body of the operative report (not just the summary) to be sure that you are reporting every procedure the surgeon performed.
 CPT includes three codes to describe lab chole, each of which is more extensive (and therefore pays at a higher rate) than the code it follows:

 

47562 - Laparoscopy, surgical; cholecystectomy
 

47563 - ... cholecystectomy with cholangiography
 

47564 - ... cholecystectomy with exploration of common duct.

"Many surgeons perform cholangiography [radiologic examination of the bile ducts] as a standard component of cholecystectomy," says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. "Because the surgeon considers the cholangiography routine, he or she may fail to note the procedure in the operative report summary. If you don't read the body of the operative report, you may miss the cholangiogram, as well as the reimbursement that comes with it."
 
Use one code to describe cholangiography and common duct exploration: If the surgeon performs both cholangiography and exploration of the common bile duct (to locate and remove gallstones, for instance) you should report only 47564. The National Correct Coding Initiative (NCCI) bundles 47563 into 47564. The edit pair includes a "0" modifier indicator, meaning that you may never override the edit. Payers will always include the work involved in 47563 into 47564.

Step 2: Look for Modifier -22 Opportunities

When reading the operative report, you should also scan for evidence of additional work - such as extensive lysis of adhesions - that may provide an opportunity for added reimbursement using modifier -22 (Unusual procedural services).
 
"You should use modifier -22 sparingly and with care. But in cases when the surgeon performs significant, documented additional work, you're doing yourself and the surgeon a disservice by not attaching the modifier," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, owner of Precision Coding and Compliance, Hackettstown, N.J.
 
Supply rock-solid documentation: Generally, coding experts recommend that the surgery should require at least 25-30 percent additional time or effort to complete before you should consider appending modifier -22. And, your documentation should specifically and explicitly describe the unusual nature of the surgery, such as the amount of additional time/effort required to complete the procedure and the reason for the difficulty, says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. You should specifically request additional reimbursement equal to the additional work the surgeon performed.
 
Coding example: During a lap chole, the surgeon encounters substantial intestinal adhesions. She spends 90 minutes removing the adhesions with the laparoscope before completing the cholecystectomy.
 
In this case, you cannot report 44200 (Laparoscopy, surgical; enterolysis [freeing of intestinal adhesion] [separate procedure]) in addition to 47562 because NCCI and CPT guidelines bundle 44200 to cholecystectomy (and provide no way to override the edit).
 
However, because lysis of adhesions required significant additional work in this case, you may report 47562-22 to indicate the unusual nature of the surgery.
 
Be sure to include the extra diagnosis for the intestinal adhesions on your claim form. Also, include a cover letter with the claim, describing why the surgeon required additional time and requesting added compensation for the extraordinary effort.

Step 3: For Conversions, Report an Open Procedure

If, during a lap chole, the surgeon must convert to an open (non-laparoscopic) surgery due to inflammation, extensive adhesions or other complications, you should report only the "successful" (that is, the open) procedure, according to correct coding guidelines.
 
Coding example: During the initial approach of a lap chole, the surgeon finds that the patient's gallbladder is severely inflamed and surrounded by difficult adhesions. The surgeon decides to abandon the laparoscope and perform an open (excisional) cholecystectomy instead. In this case, you should report 47600 (Cholecystectomy).
 
Don't report a "failed" lap chole: Because the surgeon began with a lap chole, you may be tempted to report 47562 with modifier -53 (Discontinued procedure) in addition to 47600, but this is incorrect.
 
"As long as the surgeon completes the service, you should bill the successful procedure only," said Deborah Berry, CPC, during her presentation on modifiers at the American Academy of Professional Coders' 2004 national conference in Atlanta.

For Difficult Conversions, -22 Is an Option

 f the surgeon spends a long time attempting to complete a laparoscopic procedure before ultimately converting to an open approach, you may be able to access modifier -22 to account for the extra effort and boost reimbursement, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.
 
"Often surgeons spend more time trying to perform the laparoscopic procedure than it would usually take to perform the entire procedure," Bucknam says. "If the surgeon decides he has to convert, he has the additional work of starting over. If the surgeon describes this process well, payers will often provide additional reimbursement for this additional time and work."
 
Coding example: After spending 40 minutes lysing adhesions laparoscopically and moving toward the gallbladder, the surgeon encounters excessive inflammation. Due to these complications, the surgeon decides to abandon the scope and proceed with an open approach. In this case, because of the significant additional effort, you may append modifier -22 to 47600. Again, you must be sure that documentation supports your claim.

Step 4: Use V64.4 as a Secondary Dx

If the surgeon converts a lap chole to an open procedure, be sure to include V64.41 (Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis. Using V64.41 does not affect the primary diagnosis (for instance, 575.0, Acute cholecystitis), which should remain the same, regardless of the surgeon's surgical approach.
 
You should also add additional diagnosis codes to describe the conditions that lead to the decision to change from laparoscopic to open approach. These conditions could include adhesions, abscess or others.