Practice Management Tip

Answers to Your Most Common Coding Scenarios - Coding Tips for General Surgeons

Teri Romano, RN, MBA, CPC
General surgeons perform a wide array of surgical procedures, but coding even the most common clinical scenarios can sometimes be challenging.  A few common clinical scenarios are described below with recommendations for accurate coding.

Scenario #1.
You are called to the emergency department for a 30 year old patient (non-Medicare) with appendicitis. You evaluate the patient, review the imaging and take the patient to surgery where you do a laparoscopic appendectomy for her very inflamed but non-ruptured appendix. What do you code?
Answer:  You will code an outpatient consultation with a 57 modifier for the evaluation and management (E & M) service. The 57 modifier indicates that the E & M was the decision for surgery E & M. You will also code 44970 for the laparoscopic appendectomy. 

Scenario #2
You perform a laparoscopic cholecystectomy on a patient and as part of your closure, you also repair an Incisional hernia. What do you code?

Answer: You will code only the cholecystectomy, 47560.  According to AMS and CPT guidelines, repairing an Incisional hernia as part of the closure of another abdominal procedure is included in the other procedure. CPT code 49654, for laparoscopic repair of an incision hernia should not be coded in addition to 47560 for the lap cholecystectomy.

Scenario # 3
You operate on a patient to repair his recurrent Incisional hernia, remove the mesh that was placed at the prior surgery and place new mesh.  Can you code the new hernia repair, mesh placement and removal of the mesh?

Answer:  In this scenario you would code for the hernia repair, 49656 and placement of the new mesh only, 49568. The add-on code 11008 is intended for a post-operative infection and   only for the removal of infected mesh. In addition, the code can only be used in concert with codes 10180, irrigation and drainage,  complex,  post-operative wound infection or codes 11004-11006 debridement for necrotizing soft tissue infection.

Scenario #4
You repair an umbilical hernia in a 53 year old though an open abdomen approach and place mesh. What do you code?

Answer: Repair of an umbilical hernia via an open approach is coded as 49585. Mesh placement may not be reported separately. Per CPT, mesh placement is only reported separately with repair of open Incisional hernias. 

Scenario #5
What about a laparoscopic Incisional hernia repair? Can mesh be reported separately? 
Answer:  Laparoscopic repair of an Incisional hernia, code 49564 includes mesh placement. Therefore it may not be reported separately. Per CPT, mesh placement is included in all laparoscopic hernia repairs. 

Scenario #6
You perform an open abdominal procedure on a patient with extensive adhesions from previous surgeries.  It takes you 55 minutes to lyse these adhesions before the surgery can be accomplished.  Is it appropriate to report 44005, enterolysis (freeing of adhesion) along with the code for the primary surgery?

Answer:  No, 44005 enterolysis (freeing of adhesions) for an open procedure and 44180, laparoscopic enterolysis, are both designated as “separate procedures.” They are considered integral to the primary procedure at the same anatomic site.  Although these codes would not be coded in addition to the primary abdominal procedure, a 22 modifier, for increased procedural service, could be appended to request additional payment for the addition work. An increase in payment will be dependent on the thoroughness of the documentation and payor policies.

Teri Romano is a consultant with KarenZupko & Associates, Inc., a practice management firm working nationally with surgical practices