General Surgery Coding Alert

Medicare requires you to bundle 'converted' scopes to open procedures

Most general surgery coders are familiar with coding guidelines that bundle diagnostic endoscopic procedures (such as thoracoscopy) to surgical scopes of the same type, but you can report multiple procedures if the diagnostic scope led to the decision to perform an open surgical procedure, or if the surgeon performs more than one surgical endoscopic procedure.
 
To ensure you're coding everything that your surgeon deserves payment for, follow these four tips. 1. True 'Diagnostic' Scope = Separate Payment If the surgeon performs a diagnostic thoracoscopy (six codes, 32601-32606), and the results of the examination determine the need for an "open" surgical procedure, you may report the diagnostic thoracoscopy separately, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.

National Correct Coding Initiative (NCCI) guidelines state (in three separate locations) that if the surgeon performs an endoscopy for an initial diagnosis on the same day as the open procedure, you may report the endoscopy separately.

NCCI instructions indicate that you should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the open procedure "to indicate that the diagnostic endoscopy and the open surgical service are staged or planned procedures."

"For staged procedures, I include the word 'staged' as often as possible in the procedure description, diagnosis and clinical history so that the payer knows why I am using modifier -58," Barone says. "For instance, I'll describe the procedure as 'staged open pneumonectomy after a diagnostic thoracoscopy.' "

Example: The surgeon uses diagnostic thoracoscopy to examine a patient with a pain and breathing difficulty (32601, Thoracoscopy, diagnostic [separate procedure]; lungs and pleural space, without biopsy). The surgeon identifies and locates a foreign body in the pleural space, and removes the object via incision and thoracotomy (32150, Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit).

In this case, because the thoracoscopy led to the decision to perform the thoracotomy (an open surgical procedure), you should claim both procedures, using 32601 and 32150-58.

Caution: If the surgeon uses a diagnostic scope to assess the surgical field to establish anatomic landmarks, or to discern the extent of disease, you cannot report the diagnostic scope separately. Such "scout" scopes are bundled to the surgical procedure. Rather, the diagnostic scope must lead directly to the decision to perform surgery. Extra coding tip: Do not report 32002 (Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]) in addition to thoracoscopy codes 32601-32606 and 32650-32665.

To perform thoracoscopy, the pleural space between the lung and chest wall must be large enough so that the surgeon can move the instruments around [...]