Urology Coding Alert

Modifier knowledge ends confusion

When the urologist starts a procedure laparoscopically and converts to an open surgery due to complications, make sure you consult individual carriers about whether you can report both the laparoscopy and the open procedure or whether you're limited to just one, as you are with Medicare.

Because laparoscopy is minimally invasive, it's emerging as a popular option for procedures such as nephrectomies and ureteroneocystostomies. Complications such as altered anatomy or poor visibility due to fibrosis or scarring, however, can make completing a laparoscopic procedure impossible. In such situations, the urologist is forced to complete the procedure as open. And that's when a challenging surgical situation then becomes a challenging coding situation. Report the Open Procedure for Medicare When one approach to a procedure fails and the surgeon must change to a second approach, "these procedures are considered 'sequential procedures,' " according to the National Correct Coding Policy Manual for Part B Medicare Carriers, version 10.3. The manual also states, "Only the CPT Code for one of the services, generally the more invasive service, should be reported."

The bottom line: Based on this Medicare policy, when a urologist converts a procedure from laparoscopic to open, you should only report the open procedure code. Document Additional Surgical Time One of the biggest problems coders face when they find themselves having to code for a lap-to-open procedure is "attempting to ensure the surgeon gets paid for the additional time within the limitations of proper coding," says Dan Rogers, administrator for Gulf South Urology and instructor at Healthcare Administrative Services in Biloxi, Miss.

Append modifier 22: By adding modifier 22 (Unusual procedural services) to the open procedure code, coders can account for the additional time the urologist spends attempting the procedure laparoscopically before having to convert to open. To add modifier 22, the operative report must show that the urologist performed work that was above and beyond the time and work normally required for the procedure.

Rosemary Russell, CPC, of Maine Urology Associates PA in Bangor, agrees and does exactly that. "Along with the claim form, I attach the operative report and a letter explaining the situation and the amount of extra work involved," she says.

Providing additional detailed documentation can help the coder get the most reimbursement possible. Be specific in the letter and explain the exact length of time the procedures takes. You can also indicate how much additional compensation the doctor should receive for the extra time spent on the procedure. According to coding experts, you should usually ask for at least 50 percent more. [...]