Wiki Appropriate Coding for unplanned additional procedures during planned surgery

[cmjaye@gmail.com]

I have searched high and low for an answer to this question and I cannot come to a definite conclusion.

Question: During the course of a planned surgical procedure, if the surgeon discovers some pathology requiring maneuvers that are NOT a part of the major procedure or global surgery package, something considered by the surgeon to be medically necessary and perhaps unrelated to the planned procedure, is this separately reportable? I do not have a specific example at this time.

What is known: In page 10, chapter 1 of the CMS NCCI Policy manual, it is clearly outlined what is considered integral to a planned surgical procedure... a smaller portion inclusive of a larger procedure. This chapter also covers sequential procedures, conversions, and intraoperative complications and what is not separately reportable.

But, Ch1, page 15 of NCCI Policy Manual states: "If exploration of the surgical field results in additional procedures other than the primary procedure, the additional procedures may generally be reported separately." CMS 2018 NCCI Policy Manual, Ch1, General Correct Coding Policies

Can anyone help me out with this?

 

[csperoni]

Code the same as if it was planned

You would simply code the additional procedures with whatever the code is for the procedure that is done.

General surgery example: Doc plans on removing gallbladder, 47600 but during exploration sees a mass on the transverse colon, removes it.
Code: 47600 and 44110-59 with the appropriate dx codes.

Whether the procedures are planned or unplanned, you code for whatever was actually performed. Of note, the surgeon cannot bill for repairing a mistake that he/she made.