Wiki Why was I marked wrong? (Practicode Case ID: OPD7183)

Elund

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The documentation:
Age: 39

SEX: FEMALE

DATE OF OPERATION: 11/02/20xx

PREOPERATIVE DIAGNOSIS: RIGHT SIDE TUBAL PREGNANCY.

PROCEDURES: PRIMARY LOW TRANSVERSE INCISION VIA PFANNENSTIEL MINI LAPAROTOMY. RIGHT SALPINGECTOMY

POSTOPERATIVE DIAGNOSIS: RIGHT SIDE TUBAL PREGNANCY.

SURGEON: Ezequiel M. Kramer, M.D.

FIRST ASSISTANT:

ANESTHESIA: GENERAL, ENDOTRACHEAL.

ESTIMATED BLOOD LOSS: 300 CC. AND FLUID WAS EVACUATED FROM THE PERITONEAL CAVITY.

URINE OUTPUT: 150 CC CLEAR URINE AT THE END OF THE PROCEDURE.

COMPLICATIONS: NONE.

ESTIMATED BLOOD LOSS: ABOUT 300 CC.

URINE OUTPUT: AT THE END OF THE PROCEDURE ABOUT 200 TO 250 CC CLEAR URINE.

FINDINGS: Normal anteverted uterus with closed os.

INDICATION: Right-sided tubal pregnancy.

HISTORY: The patient is a 39-year-old gravida IV, para 1-1-2-1 presenting for a laparotomy, right salpingectomy for right tubal pregnancy. The patient's history is significant for prior bilateral tubal ligation also prior tubal reversal anastomosis. The patient also has a history of diabetes controlled with p.o. Sulfonylurea. The patient presented to the emergency room with right-sided abdominal pain beta hCG in the ER showed very low 596. Ultrasound showed ectopic pregnancy. The patient was counseled about ectopic pregnancy with the risks and benefits were explained. The patient opted for operative management of the ectopic pregnancy. The patient was consulted for possible laparotomy. The consent was voluntarily obtained.

PROCEDURE: The patient was taken to the operating room where general anesthesia via the endotrachea was found to be adequate. The patient was then draped and prepped in the normal sterile fashion in the dorsal supine position. The patient was also examined under anesthesia.

A Mini Laparotomy 4cm Pfannenstiel skin incision was then made with a scalpel and carried through to the underlying layer of fascia with the Bovie. The fascia was excised in the midline and the incision extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then grasped with the Kocher clamp, elevated and underlying rectus muscles dissected off bluntly. Prior to the incision a vertical scar from the previous cesarean section of the patient was identified.

Attention was then turned to the inferior aspect of this incision, which in a similar fashion was grasped, tented up with a Kocher clamp and the rectus muscles dissected off bluntly. The rectus muscles were then separated in the midline and the peritoneum identified and tented up and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. At this point, the uterus was properly identified. Using a Babcock, the two tubes that were left through a small side ampullary tube structures were identified. On the right there was presence of the ectopic pregnancy clearly delineated at the right side of the ampullary portion of the right tube.

At this point, a survey of the peritoneum showed some old clot from the rupture of the ectopic. We evacuated and good irrigation was made. At this point, the ectopic was identified attached to it was the right ovary. Using cauterization dissector, the right tube was meticulously dissected off and the ectopic removed. The patient was cleaned of all the bleed and clots and irrigated properly. The instruments were removed. The fascia was closed with 2-0 chromic and the skin incision was closed with staples.

The patient tolerated the procedure very well. Lap counts x 2 were accurate.

____________________________

Ezequiel M. Kramer, M.D.

Why isn't the RT modifier listed for the right salpingectomy?
 
The documentation:
Age: 39

SEX: FEMALE

DATE OF OPERATION: 11/02/20xx

PREOPERATIVE DIAGNOSIS: RIGHT SIDE TUBAL PREGNANCY.

PROCEDURES: PRIMARY LOW TRANSVERSE INCISION VIA PFANNENSTIEL MINI LAPAROTOMY. RIGHT SALPINGECTOMY

POSTOPERATIVE DIAGNOSIS: RIGHT SIDE TUBAL PREGNANCY.

SURGEON: Ezequiel M. Kramer, M.D.

FIRST ASSISTANT:

ANESTHESIA: GENERAL, ENDOTRACHEAL.

ESTIMATED BLOOD LOSS: 300 CC. AND FLUID WAS EVACUATED FROM THE PERITONEAL CAVITY.

URINE OUTPUT: 150 CC CLEAR URINE AT THE END OF THE PROCEDURE.

COMPLICATIONS: NONE.

ESTIMATED BLOOD LOSS: ABOUT 300 CC.

URINE OUTPUT: AT THE END OF THE PROCEDURE ABOUT 200 TO 250 CC CLEAR URINE.

FINDINGS: Normal anteverted uterus with closed os.

INDICATION: Right-sided tubal pregnancy.

HISTORY: The patient is a 39-year-old gravida IV, para 1-1-2-1 presenting for a laparotomy, right salpingectomy for right tubal pregnancy. The patient's history is significant for prior bilateral tubal ligation also prior tubal reversal anastomosis. The patient also has a history of diabetes controlled with p.o. Sulfonylurea. The patient presented to the emergency room with right-sided abdominal pain beta hCG in the ER showed very low 596. Ultrasound showed ectopic pregnancy. The patient was counseled about ectopic pregnancy with the risks and benefits were explained. The patient opted for operative management of the ectopic pregnancy. The patient was consulted for possible laparotomy. The consent was voluntarily obtained.

PROCEDURE: The patient was taken to the operating room where general anesthesia via the endotrachea was found to be adequate. The patient was then draped and prepped in the normal sterile fashion in the dorsal supine position. The patient was also examined under anesthesia.

A Mini Laparotomy 4cm Pfannenstiel skin incision was then made with a scalpel and carried through to the underlying layer of fascia with the Bovie. The fascia was excised in the midline and the incision extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then grasped with the Kocher clamp, elevated and underlying rectus muscles dissected off bluntly. Prior to the incision a vertical scar from the previous cesarean section of the patient was identified.

Attention was then turned to the inferior aspect of this incision, which in a similar fashion was grasped, tented up with a Kocher clamp and the rectus muscles dissected off bluntly. The rectus muscles were then separated in the midline and the peritoneum identified and tented up and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. At this point, the uterus was properly identified. Using a Babcock, the two tubes that were left through a small side ampullary tube structures were identified. On the right there was presence of the ectopic pregnancy clearly delineated at the right side of the ampullary portion of the right tube.

At this point, a survey of the peritoneum showed some old clot from the rupture of the ectopic. We evacuated and good irrigation was made. At this point, the ectopic was identified attached to it was the right ovary. Using cauterization dissector, the right tube was meticulously dissected off and the ectopic removed. The patient was cleaned of all the bleed and clots and irrigated properly. The instruments were removed. The fascia was closed with 2-0 chromic and the skin incision was closed with staples.

The patient tolerated the procedure very well. Lap counts x 2 were accurate.

____________________________

Ezequiel M. Kramer, M.D.

Why isn't the RT modifier listed for the right salpingectomy?


If the description of a CPT code says that it can be “unilateral or bilateral,” you typically wouldn’t be required to report a laterality modifier with it.

Specific payers can sometimes have different requirements, so in the real world you’d always refer to the payer-specific rules.

In this case with Practicode, I’d assume that the 39 year old patient had commercial insurance.

(In the real world it’s possible that a 39 year old could have Medicare, of course, but for a Practicode case they’d specifically indicate that a 30-something patient had Medicare.)
 
What was your CPT code, 59151? If so, the code does not require RT or LT because of the anatomic structure. It also has a MUE of one due to the rationale of "anatomic consideration". This can be confusing because there are two ovaries (one uterus). The uterus can be looked at as a "midline" organ. Example: Anatomic considerations may limit units of service based on anatomic structures. For example, the MUE value for an appendectomy is “1” since there is only one appendix. Modifiers LT and RT are usually used for paired body parts like arms, legs, feet, eyes, etc. Also, the bilateral indicator is 0 on the CMS fee schedule lookup, and those codes with the 0 should not be billed with modifiers 50, LT or RT. There can be some exceptions.

In the real world, it may not get denied or rejected or cause an issue, but most commercial payers would deny it as an invalid CPT/modifier combo. It would be denied stating something like, procedure codes to which the bilateral concept does not apply are not payable when billed with modifier 50, LT or RT. There are always real world exceptions to this by payer like Susan mentioned.
If you look at the code range of 59100-59151 for example, they all have an MUE of 1 and cannot be reported bilaterally. There is no unilateral or bilateral wording in the code descriptions.
 
Thanks for your help, both of you. :)

The CPT code was 59120. I was confused because the guidelines for that section (and beneath the individual codes) didn't specify anything about laterality modifiers.
 
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