CODING AND PRACTICE MANAGEMENT CORNER Frequently asked questions about CPT coding by Jayme Lieberman, MD, FACS; Samuel Smith, MD, FACS; and Jan Nagle, MS xperts agree that correct Laparoscopy, surgical; colectomy, biopsy is performed. Current Procedural partial, with anastomosis, with How is this coded? ETerminology (CPT)* coding coloproctostomy (low pelvic If a laparoscopic biopsy of the may be the single most important anastomosis) with colostomy. It is liver is performed at the same area for surgical practice incorrect to report a code for time as another laparoscopic improvement. However, keeping ileostomy or jejunostomy (44310 procedure, report unlisted code up with the constant changes or 44187) with a partial colectomy 47379, as there is no CPT code in claims coding and billing code (for example, 44145 or for a laparoscopic liver biopsy 42 | rules can be costly and time- 44207) for this procedure, as (see Table 3, page 43). It would consuming. This column lists doing so would be unbundling. be inappropriate to report 49321, several frequently asked questions Laparoscopy, surgical; with biopsy and the correct coding responses. (single or multiple). Code 49321 is What code do I report for a reported only when a biopsy is laparoscopic appendectomy the only procedure performed. If How do I report an open for perforated appendicitis? these procedures were performed colon resection and colorectal Two codes differentiate an via an open approach, code anastomosis with loop open appendectomy without 47600 (open cholecystectomy) ileostomy for fecal diversion? rupture (44950) and with rupture would be reported with code You should report CPT code (44960). However, only one 47001, Biopsy of liver, needle; 44146 (see Table 1, page 43). code applies to laparoscopic when done for indicated purpose Although the CPT descriptor appendectomy (44970), and it at time of other major procedure includes the term “colostomy,” is used to report a laparoscopic (List separately in addition to code the Medicare physician fee appendectomy for either for primary procedure), or code schedule work relative value unit scenario; with rupture or without 47100, Biopsy of liver, wedge, as (RVU) for this code is based on rupture (see Table 2, page 43). appropriate. Unlisted codes creation of either a colostomy have a “YYY” global period, or an ileostomy. If this same which indicates they are procedure was performed A 65-year-old female contractor-priced and require laparoscopically, the correct with a remote history of documentation that provides code to report would be 44208, colon cancer undergoes a pertinent information, including laparoscopic cholecystectomy an adequate definition or *All specific references to CPT codes and for symptomatic description of the nature, extent, descriptions are © 2017 American Medical cholelithiasis. A concerning and need for the procedure, and Association. All rights reserved. CPT and CodeManager are registered trademarks lesion is identified on the the time, effort, and equipment of the American Medical Association. liver and a laparoscopic necessary to provide the service. V103 No 6 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER TABLE 1. COLECTOMY CPT code(s) to Global Work Total Relative Descriptor report period RVU Value Unit (RVU) Colectomy, partial; with coloproctostomy 44146 090 35.30 61.44 (low pelvic anastomosis), with colostomy TABLE 2. CODING FOR LAPAROSCOPIC APPENDECTOMY CPT code(s) to Global Descriptor Work RVU Total RVU report period 44970 Laparoscopy, surgical, appendectomy 090 9.45 17.40 TABLE 3. LAPAROSCOPIC LIVER BIOPSY CPT code(s) Global Descriptor Work RVU Total RVU to report period 47562 Laparoscopy, surgical; cholecystectomy 090 10.47 19.04 47379-51 Unlisted laparoscopic procedure, liver YYY 0.00 0.00 | 43 provided at that time, it may (sq cm), subcutaneous, right How do I report removal of be reported by itself, or in thigh; 45 sq cm subfascial, a lipoma of the spermatic addition to other procedures/ separate site right thigh; cord and repair of a reducible services by appending modifier 25 sq cm, subcutaneous, left inguinal hernia performed 59 to the specific “separate thigh; and 45 sq cm subfascial, at the same time, through procedure” code to indicate that separate site, left thigh? the same incision? the procedure is not considered Excisional wound debridement For this clinical scenario, report to be a component of another is reported by depth of tissue only the hernia repair code procedure, but is a distinct, removed and by total surface 49505 (see Table 4, page 44). independent procedure. This area of the wound(s). If multiple A lipoma or preperitoneal fat may represent a different separate wounds require that is within the hernia sac or session, different procedure different depths of debridement, part of the hernia repair would or operation, different site or calculate a total wound surface not be separately reported. organ system, separate incision/ area for all wounds at each Code 55520, Excision of lesion of excision, separate lesion, or depth. When choosing codes spermatic cord (separate procedure), separate injury (or area of to report, keep in mind that is a “separate procedure.” injury in extensive injuries). the CPT code numbers for Coding tip: When a procedure excisional debridement are that is designated as a “separate out of sequence. The codes procedure” is carried out How do I report the following are reported in descending independently or considered to excisional debridement work order of total RVU. be unrelated or distinct from that was performed in a facility other procedures/services setting: 30 square centimeters continued on page 45 JUN 2018 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER TABLE 4. HERNIA REPAIR WITH SPERMATIC CORD LESION CPT code(s) Global Descriptor Work RVU Total RVU to report period Repair initial inguinal hernia, age 5 years or 49505 090 7.96 15.03 older; reducible TABLE 5. DEBRIDEMENT CPT code(s) Global Descriptor Work RVU Total RVU to report period Debridement, muscle and/or fascia (includes 47562 epidermis, dermis, and subcutaneous tissue, 000 2.70 4.47 if performed); first 20 sq cm or less Debridement, subcutaneous tissue (includes 47379-51 epidermis and dermis, if performed); first 20 000 1.01 1.78 sq cm or less Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, +11046 1.03 1.62 if performed); each additional 20 sq cm, or ZZZ x4 units x4 units x4 units 44 | part thereof (List separately in addition to code for primary procedure) Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each +11045 0.50 0.76 additional 20 sq cm, or part thereof (List ZZZ x2 units x2 units x2 units separately in addition to code for primary procedure) + = add-on code TABLE 6. HERNIA CPT code(s) Global Descriptor Work RVU Total RVU to report period Muscle, myocutaneous, or fasciocutaneous 15734 090 23.00 43.56 flap; trunk Muscle, myocutaneous, or fasciocutaneous 15734-59 090 23.00 43.56 flap; trunk Repair recurrent incisional or ventral hernia; 49565-51 090 12.37 22.20 reducible Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement +49568 ZZZ 4.88 7.76 for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) + = add-on code V103 No 6 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER CODING WORKSHOPS More information about the 2018 ACS coding workshops is on the ACS website at facs.org/advocacy/practmanagement/workshops. Upcoming workshops: • Nashville, TN, August 9–10 • Chicago, IL, November 1–3 (includes a third day devoted to trauma and critical care coding) For the clinical scenario in debridement, and use the total for code pairs that have an the question, the subcutaneous wound surface area for any NCCI edit or to indicate that the debridement on the right and and all types of debridement. same procedure was performed left thighs totals 55 sq cm of For example, a single wound at a different anatomic site wound surface area and is requiring 10 sq cm of subfascial (for example, right and left reported with 11042 for the first debridement and 10 sq cm of musculofascial flaps). If no 20 sq cm and two units of 11045 subcutaneous debridement NCCI edit exists for a code pair, for the additional 20 sq cm and would be reported with 11043. then append modifier 51 to the the additional remaining 15 code(s) with the lower total RVU. | 45 sq cm (20 + 20 + 15 = 55). The subfascial debridement totals What code is reported for 90 sq cm of wound surface area repair of a recurrent, reducible Learn more and is reported with 11043 for ventral hernia with mesh and Learn more about correct the first 20 sq cm and four units both a left-sided and right- coding at an American College of 11046 for the additional 70 sided component separation? of Surgeons General Surgery sq cm (20 + 20 + 20 + 10 = 70). Report 49565 for the hernia Coding Workshop (see box, this There is a National Correct repair and 49568 for implantation page). By attending a coding Coding Initiative (NCCI) edit of mesh. Medicare guidelines workshop, you will learn how to for the code pair 11042/11043, do not allow use of modifier 50 report surgical procedures and so modifier 59 Distinct( (Bilateral procedure) with 15734; medical services and will have procedural services) should be therefore, for the work of access to the tools necessary appended to 11042 to indicate bilateral component separation, to succeed, including a coding the subcutaneous debridement report one unit of 15734 plus workbook with checklists, was performed at separate sites a second unit of 15734 with resource guides, templates, from the subfascial debridement. modifier 59 appended (see Table and examples to keep for Because 11045 and 11046 are 6, page 44).