Appendectomy versus exploratory laparotomy

Grintwig

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Fayetteville, NC
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An issue has come up in our office where several of our surgeons have had patients with right lower quadrant pain, an elevated white cell count, guarding, and rebounding. They have done appendectomies and the pathology report has come back with "no pathological diagnosis". Medicaid is refusing to pay for these procedures saying that the above diagnoses do not meet medical necessity. In these cases should we be coding appendectomies or exploratory laparotomies? I believe the only thing we can legally and morally code is the appendectomy.
The office manager argues that 789.03 is a payable diagnosis for the laparotomy and therefore since Medicaid won't pay for the appendectomy with that diagnosis we should be using the laparotomy code. She says it is virtually the same thing except the physician took out the appendix while he was in there:confused:
I feel that is wrong. The surgeon specifically stated his intent to perform and appendectomy and then performs one for right lower quadrant pain. We have sent all of the appropriate notes that contain the information about guarding and rebound and they still deny the procedures. I do not want to have to write them off but since Medicaid has no peer review process in our state they will not be paid the way they are now.
Is there something that I am missing that would help justify the appendectomy using the appendectomy code? No other procedures were done in any of these cases and all of the patients felt better after having their appendix removed:confused:
I feel like using the laparotomy code is unethical and immoral but this needs to be paid and so the office manager is telling me I had better change the code....... Can I legally change the code or is it time to change my job?
She is pretty emphatic that I "had better" get with the "program" and "get these paid however".
 

john67

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Overland Park, Kansas
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you are correct

I'm just a CPC-A still with no coding experience yet in a physician setting, but here's my take.
Code for the appendectomy. I wouldn't expect Medicaid to reimburse for a laparotomy either. And don't let the office mgr tell you they're the same thing from a CPT code point of view. CMS will come after you. I'm sure you already knew that. You said you sent in the needed medical documents from the physician performing the procedure I'm assuming. The pt must have had an inflamed appendix as well I would think in addition to the right lower pain and wbc count.
Hope my opinion helps some. Good luck!
 
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