2 surgeons same division - any suggestions?

hedmiston

Contributor
Messages
19
Location
Route 66 Coders
Best answers
0
I'm not sure how to code this case. I have 2 surgeons from the SAME division involved. Any help with the CPT & Dx codes would be greatly appreciated as I feel the codes they have provided are not completely accurate.

*Surgeon "A" billed CPT 44005, Dx K63.1 (intestinal perforation), K56.5 (intestinal adhes w/obst), K43.5 (parastomal hernia) & J44.9 (COPD)

Surgeon "A" Op report

Preop Dx: Intestinal perforation.
Postop Dx: Intense adhesions with intra-abdominal contamination, source unclear.

Indication for procedure:
Pt with COPD and a know incarcerated parastomal hernia after a sigmoid colectomy for perforated divertiulitis in 2013. Met with pt in 2015 when they had a partial SBO that resolved with nonoperative management. Pt presented to the hospital last month with an exacerbation of COPD, but was also found to have abdominal pain and developed a SBO associated with this as well. Pt initially improved, but then developed increasing pain, an elevated white count, and lethargy along with acute kidney injury manifested by an elevated creatinine. CT scan demonstrated free air. Pt comes now to the OR for exploration and determination of findings of intestinal perforation.

Findings:
Bilious contamination in areas of the abdomen. Entire lenth of the SB was run and no evidence of a perforation could be found. The stomach and duodenum were examined, no evidence of perforation could be identified.

Procedure:
Midline incision was made, careful dissection into the abdomen was undertaken. Four hours of adhesiolysis was necessary to free all the intestine and adhesions. Some adhesions were extraordinarily dense, in the course of this, 3 separate arteriotomies were made. These were stapled off and marked for future repair during the course of this operation; however, after this extensive adhesiolysis, the entire length of the SB was traced from the ligament of Treitz through to the terminal ileum and cecum. No evidence , other than our enterotomies, of a bowel perforation or injury was identified, although it is possible that one of these enterotomies predated and preceded our dissection. Also, in the course of this, the SB and LB were reduced out of the parastomal hernia. Thorough examination of the duodenum was undertake, seeking a site of perforation based on a perforated peptic ulcer; however, none was identified. At this point, Surgeon "B" assumed surgical care for the pt at my request. See their dictated note for repair of the resection of the enterotomies, repair of the small intestine, and repair of the parastomal hernia. Other than the unitentional enterotomies, there were no complications from the procedure.
------------------------------------------------------------------------------------------------------------------------------------------------------
*Surgeon "B" billed CPT 44120-59, 44121-59, 44121-59 & 44346-59, Dx J44.9, K43.5, K56.69, K56.5 & K94.09

Surgeon "B" Op report

Postop Dx: Partial SBO thought to be due to parstomal hernia, intraperitoneal free air on CT scan, parastomal hernia.

Indication for procedure:
Pt has a complicated medical hx. Todays procedure was begun by Surgeon "A" that portion is dictated separately.

Description of Procedure: I entered the OR to relieve Surgeon "A". A complete LOA had been done with exploration of the abdomen. Three inadvertent SB injuries had been made during the difficult adhesiolysis and contents of the parastomal herniawere reduced as dictated by Surgeon "A". The 3 SB injuries were resected. After these 3 areas were resected, it was found that 2 of the injuries had been close enough to warrant removal of an intervening 16-cm segmentof SB, to minimize the number of enteric anastomoses. This segment was removed. The pelvis was irrigated and a few clips placed on small bleeding points on the peritoneum in the pelvis. The RT & LT gutter were irrigated w/o identification of any other injuries or abnormalities. The splenic flexure and descending colon were explored with no evidence of any inflammation or perforations.

Following this, 2 SB anastomosed were performed........

Following this, #2 Ethibond sutures in figures-of-8 uset to primarily close the parastomal hernia. Considering the length of time the pt was on the operating table, this was the most expeditious way to bring it into the procedure. A figure-of-8 was placed inferior to the stoma and tied in place. Three figures-of-8 of Ethibond were placed superior to the stoma, then tied down and produced a nice snug aperture.

Following this, warm irrigation was done again. Kockers were placed on the midline fascia, but the abdomen could not be closed in large part due to the significant amount of bowel edema related to the underlying disease process and time the pt had been in the OR. An ABThera appliance was placed over the viscera inside the peritoneal cavity. A sponge was placed atop the inital layer and the adhesive strips then placed onto the skin. Prior to this, the skin around the colostomy was closed over itself to seal the stoma closed to safely place the appliance. The appliance was placed and hooked up to the suction. Postoperative care will be provided by Surgeon "A".

My thoughts:
I feel they should bill as co-surgeons.
Not sure if Surgeon "B" should bill 3 resections or 2 resections.
Not sure what Dx code to bill for the 3 indavertent SB injuries.
Modifier 52 for Temp closure. Can modifier 22 be used also for extensive LOA? (Doesn't seem right reduced services with increased procedural services.)

Thank you in advance!
Hope :confused:
 
Messages
811
Best answers
0
I just wanted to quickly address the co-surgeon billing - in order to qualify as co-surgeons, they would both have to be participating in the same procedure, bill the same CPT codes, and obviously add the 62. The documentation clearly shows that each surgeon did their own separately identifiable procedures, aside from the fact that they never actually worked "together" on one single procedure. They should each submit their own claims with the respective codes and no modifiers to "link" the two surgeons together.
 

hedmiston

Contributor
Messages
19
Location
Route 66 Coders
Best answers
0
When a surgeon performs a procedure "lysis of adhesions" is normally included. The intent of the first surgeon was to explore for a perforation and four hours of adhesiolysis was necessary. From past experiences, when a general surgeon is called to lys adhesions for an OBGYN, 44005 has been billed but not always reimbursed. I've read that they could have billed as co-surgeons. That's why I was thinking possibly billing co-surgery because these 2 surgeons are from the same division. Then with temp closure of the abdomen, modifier 52 will need appended. Just wanted some opinions of how others have handled this type of scenrio. Thanks!
 
Messages
811
Best answers
0
There's a couple of problems going on here that will definitely affect the coding.

First: Regarding the 3 unintentional enterotomies (aka sb injuries) made by Surgeon A. It's my understanding that the repair of these would not be billable because they occurred during the LOA. It's the "you break it, you buy it" standard.

The NCCI policy manual states "If an iatrogenic laceration/perforation of the small or large intestine occurs during the course of another procedure, repair of the laceration/perforation is not separately reportable. Treatment of an iatrogenic complication of surgery such as an intestinal laceration/perforation is not a separately reportable service. For example CPT codes describing suture of the small intestine (CPT codes 44602, 44603) or suture of large intestine (CPT codes 44604, 44605) should not be reported for repair of an intestinal laceration/perforation during an enterectomy, colectomy, gastrectromy, pancreatectomy, hysterectomy, or oophorectomy procedure."

So Surgeon B (unfortunately) shouldn't bill for the repair/resections per the above policy guidelines. That eliminates codes 44120 and both 44121's.

That leaves Surgeon A with 44005 and Surgeon B with 44346. I checked the edits on these codes and 44005 bundles with 44346 as a component of and no mod is allowed to break the bundle. I realize they are for different providers, but after checking into that, it appears 44005 will still be denied because it's the "same session." I do think a 22 mod is appropriate for what Surgeon A did, but if you can't get 44005 paid, then it's really not worth debating.

But here's what I'm thinking, and I could be totally wrong; based off the edits, if 44005 is a component of 44346, then technically that means Surgeon A participated in what's included in 44346. So how about billing 44346 for both Surgeon A and B with a 62? I know they the same specialty, however because each dictated the portion of the procedure they did AND (IMO) the medical necessity requirement has been met, based off Surgeon A's portion alone. I'm not sure you could get a 22 to fly if you add it also.

I don't know if that helps.
 

hedmiston

Contributor
Messages
19
Location
Route 66 Coders
Best answers
0
The NCCI policy manual states "If an iatrogenic laceration/perforation of the small or large intestine occurs during the course of another procedure, repair of the laceration/perforation is not separately reportable. Treatment of an iatrogenic complication of surgery such as an intestinal laceration/perforation is not a separately reportable service. For example CPT codes describing suture of the small intestine (CPT codes 44602, 44603) or suture of large intestine (CPT codes 44604, 44605) should not be reported for repair of an intestinal laceration/perforation during an enterectomy, colectomy, gastrectromy, pancreatectomy, hysterectomy, or oophorectomy procedure."

I agree with the NCCI policy manual for suture repair but it doesn't mention resections. Here is a link http://bulletin.facs.org/2014/05/reporting-patient-safety-indicator-15/# that suggests billing resections. Please review and advise.
Thanks again!
 
Messages
811
Best answers
0
Here's how I looked at it -

From Surgeon A's note:
"... Other than the unintentional enterotomies, there were no complications from the procedure."
From Surgeon B's note:
"A complete LOA had been done with exploration of the abdomen. Three inadvertent SB injuries had been made during the difficult adhesiolysis and contents of the parastomal herniawere reduced as dictated by Surgeon "A". The 3 SB injuries were resected. After these 3 areas were resected, it was found that 2 of the injuries had been close enough to warrant removal of an intervening 16-cm segment of SB, to minimize the number of enteric anastomoses. This segment was removed. The pelvis was irrigated and a few clips placed on small bleeding points on the peritoneum in the pelvis. The RT & LT gutter were irrigated w/o identification of any other injuries or abnormalities. The splenic flexure and descending colon were explored with no evidence of any inflammation or perforations... "

From those pieces of the narratives, I interpreted the 3 sb injuries to be the unintentional enterotomies, and 3 resections were required to completely repair. I know the policy doesn't specifically address resections, however, it does state that repair/treatment is not reported. In order to treat the injuries, the repair necessitated the resections. In other words, any work that had to be done to correct or repair the injuries would not be reported, whether that be repair with sutures or repair by resection.

I took the policy statement:
"If an iatrogenic laceration/perforation of the small or large intestine occurs during the course of another procedure, repair of the laceration/perforation is not separately reportable. Treatment of an iatrogenic complication of surgery such as an intestinal laceration/perforation is not a separately reportable service. For example CPT codes describing suture of the small intestine (CPT codes 44602, 44603) or suture of large intestine (CPT codes 44604, 44605) should not be reported for repair of an intestinal laceration/perforation during an enterectomy, colectomy, gastrectromy, pancreatectomy, hysterectomy, or oophorectomy procedure."

and took out the "Example", leaving just the policy:

"If an iatrogenic laceration/perforation of the small or large intestine occurs during the course of another procedure, repair of the laceration/perforation is not separately reportable. Treatment of an iatrogenic complication of surgery such as an intestinal laceration/perforation is not a separately reportable service."

That's how I got the understanding that "repair" including any necessary actions or procedures to correct the problem.

Does that make sense?

I also wanted to add that had the documentation stated the enterotomies were necessary to complete the procedure, then it would be totally different.
 
Top