Question Need help figuring out what is included in procedure

KDorner1

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I am having some trouble with figuring out if something is included in a procedure when it is not listed in the instructions, guidelines, etc.

For example - The procedures done were exploratory laparotomy, lysis of adhesions, removal of abscess wall, appendectomy, irrigation and placement of JP drain, partial omentectomy.

I understand that the main procedure was the open appendectomy and that many things were included in that, but I could not find any instructions/guidelines that tell me if the omentectomy is included, so when answering that question I coded for the omentectomy as well, and that was wrong. Answer was 44960 only.

I am running into this problem quite a bit, where I understand the main procedure and choosing a code that includes any additional things that were done with that procedure, but am having trouble determining what to do if something is not included in the code and I can't find any instructions or guidelines regarding that other procedure.

Can anyone give me some advice/help on this? I really want to understand it so that I can code procedures correctly in the future. Thank you in advance!!!
 

csperoni

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Are you familiar with NCCI edits? For example, in your case
44960 Appy
49255 Omentectomy
49255 is a CCI edit for 44960 and you may not override with a modifier (even if the modifier is appropriate).
CMS lists the NCCI edits on their website. It is a very cumbersome website and file to maneuver. Anyone I know who works as a coder has access to some type of encoder software (or sometimes even built into their billing system) that will alert them for edits. If you work as a coder and don't have this software, I would encourage you to ask your employer for it.
There are some things (like exploratory laparotomy) that are ALWAYS included in any other procedure. Lysis of adhesions is virtually always included (I can't think of one, but there may be something that doesn't bundle). If the lysis is extensive and time consuming and it's appropriate, you can consider -22 on primary procedure.
 

KDorner1

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Are you familiar with NCCI edits? For example, in your case
44960 Appy
49255 Omentectomy
49255 is a CCI edit for 44960 and you may not override with a modifier (even if the modifier is appropriate).
CMS lists the NCCI edits on their website. It is a very cumbersome website and file to maneuver. Anyone I know who works as a coder has access to some type of encoder software (or sometimes even built into their billing system) that will alert them for edits. If you work as a coder and don't have this software, I would encourage you to ask your employer for it.
There are some things (like exploratory laparotomy) that are ALWAYS included in any other procedure. Lysis of adhesions is virtually always included (I can't think of one, but there may be something that doesn't bundle). If the lysis is extensive and time consuming and it's appropriate, you can consider -22 on primary procedure.
Thanks so much for the info!! I will look at the NCCI edits from now on!
 

KDorner1

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Thanks so much for the info!! I will look at the NCCI edits from now on!
One more quick question I just thought of. So if the other code is not listed as an edit for my main code and there is no information in the guidelines or instructions regarding this, would you say that usually means it is fine to report both codes?
 

csperoni

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Yes, USUALLY. If there is no NCCI edit, each procedure is described and provided and it is not another guideline (like suturing the operative wound), then report both.
Here is the CMS NCCI link, but be warned - an encoder is far preferable.
 
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