Question Appendectomy vs colectomy

Merlin0728

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We are coding a surgery for a Laparoscopic appendectomy with partial cecectomy. Based on the clinic note, both procedures were planned due to an appendiceal orifice polyp. We have two different opinions. Should this be a 44970 Laparoscopic appendectomy or 44204 (52) Laparoscopic colectomy, partial, with anastomosis? Or??
Any input would be greatly appreciated. Thank you

Operative Report
PreOperative Diagnosis: [Appendiceal orifice polyp]

PostOperative Diagnosis: Same

Operative Procedure: Laparoscopic appendectomy with partial cecectomy

Surgeon: XXXX

Anesthesia:: General With local and port sites

Assistant(s): XXXX

Specimen/Tissue Removed: Appendix And the extent cecal base

Estimated Blood Loss: 50 ML's

Replacement: 1 L crystalloid

Drains: []

Complications: None apparent

Findings: []

Procedure In Detail: With consent on the chart and the patient seen by myself he was brought to the operating room postoperative table in supine position. After initiation adequate general endotracheal anesthesia the patient's abdomen was prepped and draped in usual sterile fashion. 1% lidocaine quarter percent Marcaine reason for to skin and subcutaneous tissues in the infraumbilical area and a curvilinear incision was made. Subcutaneous tissue were divided down to the anterior abdominal fascia anchoring sutures were placed the fashion was elevated the midline and opened with the Bovie electrocautery the peritoneum was incised sharply. The Hassan port was placed and CO2 pneumoperitoneum was established. The patient was placed head down and rotated to the left position a suprapubic 5 mm port in the left lateral 10 mm port were placed under direct visualization after infiltrating the skin and subcutaneous tissue local anesthetic. The appendix identified and the grasped and elevated toward the anterior abdominal wall the cecum was mobilized along the white line of Toldt as well as around the ileocecal valve. The grasper was used to palpate around the base of the appendix and a deftly felt 4 so the mesial appendix was controlled using a LigaSure device. Anatomy took a portion of the cecal base as well as the appendix with 2 firings of an endoscopic GIA stapler. The specimen was then laced in an Endo Catch bag and withdrawn. There was some bleeding down around the edge of the mesenteric resection should this was grasped and this was controlled using a clip applier with excellent result. The area was copiously irrigated hemostasis was excellent. Irrigation fluid was then removed to the best of my ability. The visual inspection of the remainder the abdominal organs that were easily seen did not show any other gross abnormality. The ports were removed the infraumbilical fascial defect was closed using 0 Vicryl in a figure-of-eight fashion. The skin incisions were closed using 4-0 Monocryl in a subcutaneous take her fashion the abdomen was washed and dried and benzoin and Steri-Strips were then applied. At the conclusion of the procedure the appendix at the area the cecum was opened and followed to the base of the appendix and the polyp was indeed in the appendiceal orifice. With no other involvement slightly we had the entire specimen. This be sent to pathology for further evaluation. At the conclusion of the procedure the patient was extubated and taken to the recovery room in stable condition. Needle and sponge counts are correct ×2.
 

thomas7331

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Just my thoughts here and others may disagree - I would code this with 44970 because the partial cecectomy here appears to be incidental to the appendectomy (it seems that only a small portion of the cecum was removed close to the appendix and the documentation doesn't show that this was a significant amount of extra work) and because the cecectomy did not require an anastamosis, which is a big part of the work involved with 44204. If the provider had documented how much extra time and work was involved in the partial cecectomy, the you could consider 44970-22, but that isn't the case and it appears that the only extra work really was the larger specimen and the control of some minor bleeding.

I would not use 44204-52 because 44204, even with the 52 modifier, is a much more intensive procedure (26.42 RVUs vs. only 9.45 for 44970) and is also classified as an inpatient-only procedure on the facility side. A cecectomy was not the intent of this procedure and I think that 44204 would misrepresent the actual work done here. If you're uncomfortable with 44970, I would personally rather use an unlisted code, e.g. 44238, than 44204.
 
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Merlin0728

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Just my thoughts here and others may disagree - I would code this with 44970 because the partial cecectomy here appears to be incidental to the appendectomy (it seems that only a small portion of the cecum was removed close to the appendix and the documentation doesn't show that this was a significant amount of extra work) and because the cecectomy did not require an anastamosis, which is a big part of the work involved with 44204. If the provider had documented how much extra time and work was involved in the partial cecectomy, the you could consider 44970-22, but that isn't the case and it appears that the only extra work really was the larger specimen and the control of some minor bleeding.

I would not use 44204-52 because 44204, even with the 52 modifier, is a much more intensive procedure (26.42 RVUs vs. only 9.45 for 44970) and is also classified as an inpatient-only procedure on the facility side. A cecectomy was not the intent of this procedure and I think that 44204 would misrepresent the actual work done here. If you're uncomfortable with 44970, I would personally rather use an unlisted code, e.g. 44238, than 44204.
Thank you for taking the time to reply!
One issue we are having is that the 44204 was the code submitted for prior authorization however the surgery ended up being done as an outpatient procedure. We have one opinion that it should be 44204 with a 52 modifier because the anastomosis was not done but the surgeon planned on doing a cecectomy and appendectomy. The other opinion is to code 44970 because the cecectomy does appear to be incidental and this is an outpatient procedure.
Have a great day!
 

thomas7331

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Thank you for taking the time to reply!
One issue we are having is that the 44204 was the code submitted for prior authorization however the surgery ended up being done as an outpatient procedure. We have one opinion that it should be 44204 with a 52 modifier because the anastomosis was not done but the surgeon planned on doing a cecectomy and appendectomy. The other opinion is to code 44970 because the cecectomy does appear to be incidental and this is an outpatient procedure.
Have a great day!
You are welcome!

Looks like you are in a Catch-22 situation - code 44970 and fight with the insurance over the code not being authorized, or code 44204-52 and fight with them over the patient being treated as an outpatient. Choose your battle. Are you coding the physician's or the hospital's services, or both? I'd suggest you coordinate (in a compliant manner of course) to make sure you're in agreement and that both are the same - if one is billed differently from the other, that will create additional problems with the payer. I would still go with my recommendation of using 44970, especially now given you say this was done as an outpatient service as it seems the procedure was less intense than originally planned. Good luck!
 

Merlin0728

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You are welcome!

Looks like you are in a Catch-22 situation - code 44970 and fight with the insurance over the code not being authorized, or code 44204-52 and fight with them over the patient being treated as an outpatient. Choose your battle. Are you coding the physician's or the hospital's services, or both? I'd suggest you coordinate (in a compliant manner of course) to make sure you're in agreement and that both are the same - if one is billed differently from the other, that will create additional problems with the payer. I would still go with my recommendation of using 44970, especially now given you say this was done as an outpatient service as it seems the procedure was less intense than originally planned. Good luck!
I am coding the physician's charges and would like to use 44970 while the hospital coder was thinking 44204(52) but is willing to reconsider. We were looking for an outside opinion before making the final decision. Your are right! Either way is going to be a problem with the insurance.

Thank you for all of your help!
 

MelBarclay

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I agree, this is one you are going to work for payment but I always find it's easier to deal with the change in procedure/codes than modifier 52. I don't know how many days out you are but you can always call to update the code post op. We recently had a BCBS that wouldn't let us update the code but noted the medical necessity and paid our procedure without a delay.

Good Luck!
 

Merlin0728

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Thank you for the advice! It's nice to hear what experiences other coders are having and how insurance companies are processing claims. We are going to code 44970 and see how Quartz processes the claim.

Have a great day!
 
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