Coder's Corner

by R. Lawrence Reed III, MD, FACS, FCCM & Thomas Esposito, MD, MPH

A 20-year-old male arrives at the trauma bay with a gunshot wound (GSW) to the left thigh. The GSW is located on the distal medial thigh, in proximity to Hunter’s Canal. There is no exit wound. Primary survey is intact, but secondary survey is notable for absent left lower extremity pulses, from the popliteal artery distally. Portable radiograph demonstrates a left distal femur fracture with a single retained bullet. The patient is taken to the operating room by the trauma surgeon. Left groin and medial thigh incisions are performed. The left SFA is isolated for proximal control. Through the left medial thigh incision, a left SFA transection is noted. The proximal and distal SFA are identified and clamped, and due to the length of the arterial injury, a reverse saphenous vein bypass is necessitated. A right groin incision is made, with an appropriate length of saphenous vein harvested. At this time, a second GSW patient arrives in the trauma bay, and the trauma surgeon consults vascular surgery. When the vascular surgeon arrives, the trauma surgeon scrubs out and proceeds to the trauma bay, while the vascular surgeon completes the bypass and closes all incisions.

What can/should the trauma surgeon bill for?

Response by R. Lawrence Reed II, MD, FACS, FCCM:

The trauma surgeon should document, and bill for, his initial history and physical (CPT 99223: Initial Hospital Care, 5.74 total RVUs, 3.86 wRVUs) along with modifier 57 to indicate that this H&P is not included in the global surgical package because it involved the decision to operate. Without the 57 modifier, the default assumption would be that the global surgical package period of the operation was active, and therefore, no additional payments for evaluation and management (E&M) services are warranted. With appropriate documentation of the H&P (i.e., a comprehensive history, a comprehensive physical examination, and medical decision-making of high complexity), and with the addition of modifier 57, this E&M service should be paid; any denials of its payment should be appealed.

The initial operative code the trauma surgeon should use is 20103 (Exploration of Penetrating Wound [separate procedure]; Extremity: 16.72 total RVUs, 5.34 wRVUs): as the trauma surgeon completed the procedure prior to starting the bypass graft, he is the only physician charging this code.

There is no specific CPT code for excision of a saphenous vein graft. That procedure is included with the code for the femoral-popliteal bypass itself, which is code 35556 (Bypass Graft, with Vein; Femoral-popliteal: 40.78 total RVUs, 26.75 wRVUs).

The combination of a wound-exploration code with the arterial bypass code may give some coders pause because of the “separate procedure” term included in its description. When the term “separate procedure” is present in a code’s description, it usually means that the procedure is a component of a more complex service; it is not a procedure that is usually identified separately. For example, lysis of adhesions (erroneously termed “enterolysis” in the CPT lexicon) carries the “separate procedure” term in its description, as some adhesiolysis (the proper term) is common in abdominal procedures. Payment for adhesiolysis only occurs if that is the only abdominal procedure being performed. In this case, however, the exploration of an extremity wound is not a routine component of a femoropopliteal bypass.

The 20103 code identifies surgical exploration and enlargement of the defect, dissection, debridement, any foreign body removal, and cauterization of smaller blood vessels. If any extensive repairs are performed on structures, organs, muscles, major blood vessels, or subcutaneous tissue of the extremity, they should be reported with the appropriate repair code—in this case, the 35556 code. The 20103 code requires a 59 modifier (Distinct Procedural Service) to ensure its full payment. Because the vascular surgeon only participated in the single 35556 procedure, he or she does not need to include a modifier.

Finally, as both the trauma surgeon and the vascular surgeon participated in performing the femoropopliteal bypass procedure as primary surgeons, each should bill for the 35556 code with, importantly, the 62 (“Two Surgeons”) modifier. This will provide 62.5 percent of the normal total payment for the code to each surgeon. Without the modifier, billing the same code for each surgeon would, at best, pay 100 percent of the payment to only one of the surgeons or, at worst, open the potential for an investigation regarding fraud and abuse. Also, to justify payment to two surgeons, each surgeon must provide an operative summary detailing the specific aspects of the procedure he or she performed.

(As an aside, it is interesting to note that there are no Correct Coding Initiative [CCI] conflicts for billing the 35556 code on the same patient during the same day by the same surgeon who performs the extremity exploration [20103]. However, when a trauma surgeon performs an exploratory laparotomy and inspects the entire abdomen before repairing and/or removing the injured structures, there is no ability to bill for the laparotomy itself [CPT 49000] because it cannot be billed during the same operative encounter as any other procedure being performed via laparotomy. This inability to bill for a trauma exploratory laparotomy, unless it’s a completely non-therapeutic exploration, is an unreasonable financial penalty applied to trauma surgeons by CMS. However, with some commercial payers, it is possible to be paid separately for a trauma laparotomy dictated as a diagnostic procedure with a separate operative report for the intra-abdominal repairs resulting from the laparotomy’s findings.)

Assuming the current RVU conversion rate of $35.9996 per RVU and no specific locality (as the payments are adjusted from region to region based upon cost of living differences), the total payments should approximate the amounts demonstrated in the Table.

Response by Thomas Esposito, MD:

We agree with Dr. Reed that the surgeon should bill code 99223 with a 57 modifier. However, we are of the more conservative group of coders who would take pause and do not believe the trauma surgeon can bill both 20103 and 35556, even with the 59 modifier. Our approach would be to either bill the 20103 alone or bill the 35556 code with a 62 modifier. The more lucrative and accurate practice would be the latter as the trauma surgeon did perform the vein harvest and wound exploration. This allows credit for the vein harvest since there is no separate code for that.