Wiki Please help! Newly certified coder

[cheryl.vanklingeren]

My doctor wants to bill 58662 & 44180. I informed him that this is not allowed as 44180 is considered part of 58662 but he is not happy with this and wants further research done. I have tried billing 44180 in the past with a 22 modifier (for another doctor), appealing with documentation and have never won an appeal in this situation. My question is: does anyone know what exactly has to be documented in order to get these paid? Time spent? He does have documented 'extensive lysis of adhesions' but I don't think that's enough. Any help/advice would be much appreciated!

 

[CodingKing]

'extensive lysis of adhesions' isn't detailed enough. Is it documented how much extra time, number, density, size, etc? the word extensive is to subjective.

For instance per an AAPC blog post some examples of things the physician may need to make note of in the op report.:

https://www.aapc.com/blog/32385-coding-lysis-of-adhesions/

Whether you report a separate CPT® code or add modifier 22 Increased procedural service to the primary procedure code, documentation is crucial. The surgeon must give a clear picture describing the difficulty encountered in the procedure. For example, did the adhesions distort the anatomy? Were they dense and fibrous? How much time was spent removing the adhesions before viewing the surgical field? Above all, the documentation must establish that lysis of adhesions was unusually complex and time consuming, for a given procedure.