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ers, you will not usually find commercial Use of “complication” Melanie Witt, RN, insurance denying the repair of the com- triggers Medicare denial CPC-OGS, MA plication during surgery. Independent coding and During a sling procedure for stress uri- documentation consultant; Qnary incontinence, the surgeon acci- former program manager, Department of Coding and dentally knicked the bladder, which was Few payers deny Nomenclature, American College then repaired, and a cystoscopy was also of Obstetricians and Gynecologists performed. These procedures were denied unlisted procedures as included in the sling procedure. This was We plan to perform a laparoscopic a Medicare patient. Qright salpingo- and Unfortunately, your coding ran afoul laparoscopic removal of the . The A of established National Correct patient had a previous laparoscopic Coding Initiative (NCCI) bundling and gen- supracervical and is now eral guidelines. having abnormal bleeding and right lower I assume that you appropriately used® quadrantDowden pain. HealthI know that Media the code for the ICD-9-CM code 998.2 (Accidental the RSO is 58661 (Laparoscopy, surgical; puncture or laceration during a procedure) with removal of adnexal structures [partial when billing for the sutureCopyright of the bladderFor personalor total oophorectomy use and/oronly salpingecto- (51860, Cystorrhaphy, suture of bladder my]), but how should we report the wound, injury or rupture; simple or 51865, removal of the cervix? …….; complicated). Although there is a CPT code for a tra- Although neither of these codes is A chelectomy (57530, Trachelectomy FAST TRACK bundled with the sling procedure (57288, [cervicectomy], amputation of cervix [sepa- The code Sling operation for stress incontinence rate procedure]), this code cannot be report- [eg, fascia or synthetic]), the general rules ed because the procedure was performed for trachelectomy for NCCI state: “When a complication laparoscopically. CPT rules dictate that cor- cannot be reported described by codes defining complica- rect coding would be an unlisted laparo- if it is done tions arises during an operative session, a scopic code. laparoscopically separate service for treating the compli- cation is not to be reported.” The use of 2 options the complication diagnosis would trigger This leaves you with 2 coding options. the denial. Because the cervix is part of the , the In addition, you apparently billed code code 58578 (Unlisted laparoscopy proce- 52000 (Cystourethroscopy [separate pro- dure, uterus) would be appropriate. If you cedure]), and this code is bundled into choose this option, you would report code 57288 with a “0” indicator, which 58661, 58578-51. Alternatively, you could means that the edit cannot be bypassed add a modifier -22 (Unusual procedural using any modifier. services) to code 58661. Whichever option you choose, you will need to send documen- The good news tation with the claim to explain the unlisted These rules would only apply to procedure or the additional work. Medicare or to payers who use Medicare I prefer the first option because it will rules. Although you may find that 52000 give you the opportunity to set your fee to may be a common bundle by many pay- account for the actual work performed.

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Most payers will not deny unlisted pro- longer be correct. In this case, the more cor- cedures so long as they are not considered rect code would be 652.13 (Breech or other investigational or experimental, a concept malpresentation successfully converted to that should not apply to this surgery. cephalic presentation; antepartum condition or complication) if the version was success- ful or 652.03 (Unstable lie; antepartum con- Modifier needed dition or complication) if it was not. to bill for anesthesia An external cephalic version was per- 2 procedures in 10 days Qformed on a breech baby as an outpa- tient procedure. I was told I could bill will trigger bundling 01958 (Anesthesia for external cephalic Our patient is scheduled for a cesare- version procedure) for the anesthesia, but Qan delivery, but the surgeon wants to have gotten an insurance denial because excise a large keloid scar prior to the the “CPT and ICD logic do not match.” cesarean. How should this be coded? We used the diagnostic code 652.2. Are I am not sure by your question of the there some rules about anesthesia I should Asequence or timing of events. be aware of? If the physician is taking the patient to There may be more than 1 problem surgery to do only the keloid excision, you Ahere. First, the anesthesia codes are have several codes to select from, depending meant to be billed by the anesthesiologist, on the type of closure. The excision of the not the physician who is also performing the keloid scar would be reported using procedure. You have not indicated whether 11400–11406 (Excision, benign lesion this was the case. including margins, except skin tag [unless If you did perform the version proce- listed elsewhere], trunk, arms or legs), where dure as well as providing the anesthesia to the code selected depends on the document- the patient, you would need to indicate this ed size of the scar removed. FAST TRACK by adding a modifier -47 (Anesthesia by sur- If it is simple closure, no additional code Anesthesia codes geon) to code 59412 (External cephalic ver- is reported, but if the closure is either inter- sion, with or without tocolysis). You would mediate or complex, you will add a code are meant then report a 2nd code for the type of from the repair section (12031–12037 or to be billed by regional anesthesia you administered. For 13100–13102). But again the size in cen- anesthesiologists instance, if you used epidural anesthesia, you timeters must be documented in order to use would report 59412-47, 62311 (Injection, these codes. single [not via indwelling catheter], not Also remember that if the surgeon per- including neurolytic substances, with or forms the cesarean within 10 days of the without contrast [for either localization or keloid excision, he/she will be in the glob- epidurography], of diagnostic or therapeutic al period for these codes and might have to substance[s] [including anesthetic, antispas- use a modifier -79 (Unrelated procedure or modic, opioid, steroid, other solution], service by the same physician during the epidural or subarachnoid; lumbar, sacral postoperative period) on the global OB [caudal]). code you report. If the keloid is excised at If you were only providing the anesthe- the time of the cesarean, it will be included sia, then code 01958 is correct, but now the by most payers as part of establishing the payer is indicating a mismatch between the operative site and incision closure. ■ CPT code and the diagnosis code. You have indicated that you used code GOT A CODING QUESTION? 652.2 (Breech presentation without mention of version). But as you are billing for anes- Send it to [email protected]. We’ll answer as many questions as space permits. thesia for a version, this code would no

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