Part B Insider (Multispecialty) Coding Alert

Published on Wed Oct 12, 2005 PDF

You can double your reimbursement for combined fistula approach

You'd better scan your surgeon's charts carefully, or you might miss out on extra reimbursement for gastrointestinal surgeries in 2006.

The Centers for Medicare & Medicaid Services has released RVUs for the new CPT codes for 2006. In many cases, those RVUs are a lot higher when the surgeon does something additional, such as creating a pouch or resection.

Example 1: You'll only receive 47.83 facility-based RVUs for new code 45395 (Laparoscopic removal of rectum). But you'll receive 51.96 RVUs if you can bill 45397 (... with pouch). Pay attention to whether your surgeon created a pouch in the same session as removing the rectum.

Hint: Oftentimes surgeons won't state whether they created a pouch, but they'll list the type of staplers they used, and in which order, according to M. Trayser Dunaway, a Camden, SC surgeon. A laparoscopic surgeon may use a GIA stapler to make the pouch and an end-to-end anastomosing stapler to attach it. Take your surgeon aside and ask which staplers may signify pouch construction.

Example 2: Similarly, you can receive 27.93 RVUs for billing 45400 (Laparoscopic proctopexy)--or 37.86 RVUs for billing 45402 (...with sigmoid resection). Usually, the medical record should state that the surgeon removed the sigmoid colon, Dunaway notes.

Also, there's a new add-on code for laparoscopic take-down of the splenic flexure: 44213 will pay 5.16 RVUs in the facility setting, so you should pay attention when your surgeon performs this service.

Example 3: If your surgeon only revises or removes a gastric port (as part of a gastric restrictive procedure), you'll bill 43886 or 43887 and receive only 7.24 or 7.39 RVUs in a facility setting. But if the physician removes and replaces the gastric port (43888), you can receive 10.27 RVUs. So look for signs that the physician actually replaced the port after removing it.

Example 4: Pay attention to whether your surgeon repairs an ileoanal pouch fisula via the transperineal approach (46710) or a combined transperineal/transabdominal approach (46712). The double approach pays more than double the single approach, 52.74 RVUs instead of just 25.15 RVUs in the facility setting.

New codes for laparoscopic gastric bypass procedures (43770-43774) pay between 23.42 RVUs and 30.66 RVUs. Anorectal diagnostic exam code 45990 pays 2.76 RVUs and new code 46505 (Chemodenervation of the anal muscle) pays 6.05 RVUs in the non-facility setting and 4.97 RVUs in the facility.