Coder's Corner

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

Here are a scenario and questions for the next Coders’ Corner from Dr. David Skarupa of the University of Florida College of Medicine - Jacksonville. This is the first part of a 3 case series:

1^st Case:  Unknown age male shot in left flank with retained bullet right flank.

Procedures:

• Exploratory laparotomy
• Exploration of retroperitoneum
• Small bowel resection x3 left in discontinuity
• Partial colectomy left in discontinuity
• Mobilization of splenic flexure
• Multiple mesenteric defects sutured
• Central line
• Arterial line
• Open abdomen and VAC
• Foley

Procedures on takeback

• Exploratory laparotomy
• Exploration of retroperitoneum
• Small bowel anastomoses x3
• Colon anastomosis x1
• Removal of foreign body
• Hernia repairs
• Open abdomen and VAC

Questions:

• How to code the first list of procedures?
• How to code the second list of procedures in the damage control sequence?

Response from Dr. Esposito:

Procedures:

• Exploratory laparotomy- Not billable with other procedures performed in the abdomen.
• Exploration of retroperitoneum- Exploration for retroperitoneum is through same initial incision & therefore not billable.
• Small bowel resection x3 left in discontinuity- 44120-52 (20.82 WRVU), 44121-52 (4.44 WRVU) x2
• Partial colectomy left in discontinuity- 44140-52 (22.59 WRVU)
• Mobilization of splenic flexure- 44139 (2.23 WRVU)
• Multiple mesenteric defects sutured- bundled, no modifier allowed to unbundle
• Central line-36556 (1.75 WRVU)- assuming non-tunneled. Apparently this does not generate a “bundled” edit and therefore does not require a 59 modifier.
• Arterial line-36620-59 (1.00 WRVU)
• Open abdomen and VAC- 97605 (.55 WRVU) if wound is 50 sq. cm. or less, 97606 (.60 WRVU) wound over 50 sq. cm.
• Foley-Not billable. Per the NCCI (National Correct Coding Policy) insertion of a foley is a component of the surgical package. One cannot separately report placement with surgical procedure when performed at the time of, or just prior to, the procedure.

Procedures on takeback

• Exploratory laparotomy- Not billable for same reasons as above.
• Exploration of retroperitoneum- Not billable for same reasons as above.
• Small bowel anastomoses x3- 44130-58 (22.11 WRVU), 44130-58-59, 44130-58-59
• Colon anastomosis x1- 44130-58-59 (22.11 WRVU)
• Removal of foreign body- Not billable
• Hernia repairs- Not billable
• Open abdomen and VAC- 97605 or 97606 depending on wound size

 Response from Dr. Reed:

Dr. Esposito and his assistant have correctly addressed the key points of this exercise and have done so – as they have described – “very succinctly”.  I have provided information in the tables and comments below to clarify and provide a more detailed rationale for the coding issues.

1st Case: Unknown age male shot in left flank with retained bullet right flank.

This is a complex case with many challenging issues.  The most problematic of these issues is that of how to bill the damage control approach for intestinal injuries.  Even though damage control has become a standard surgical practice for severely injured unstable patients over the past 25 years,^1,2 there are still no CPT codes that are specific to the process of leaving the bowel in discontinuity once contamination is controlled and returning a few days later for restoration of intestinal continuity.  Instead, surgeons and their billing staff must choose between several potentially valid options.  Please refer to the comments for more thorough explanations of the concepts involved.

Initial Operation (See Table 1):

Comments (See Table 1):

1. A laparotomy (and relaparotomy) is only billable if it is the only procedure performed at that time on that patient through that incision. In other words, a negative laparotomy can be billed separately, but not when the laparotomy is a diagnostic procedure and identifies other conditions that require surgical attention.  This is a result of the “Correct Coding Initiative” (CCI) was established by Medicare in 1996 in order to prevent “unbundling” of procedures and services by physicians.  For example, prior to CCI, it was possible to bill for a lipoma excision as well as a wound closure with locally advanced flaps, thereby “unbundling” key components of a complete procedure.  Because many intraabdominal procedures require a laparotomy, the laparotomy itself is not billable, which includes the opening and closing of the abdominal wall as well as any obtaining any tissue samples obtained.  However, it is interesting to note that several of the procedures considered to include a laparotomy actually provide fewer RVUs than the laparotomy.³ It is also interesting to note that, since that manuscript’s publication, several of those procedures (listed in Table 1 of that publication) now carry more RVUs than a laparotomy provides.  However, several of the listed codes (38564, 43830, 43831, 43870, 44800, 44850, 49560, 49565, 49570, 49572, 49580, 49585, 49587, 49590, 58940, and 64760) still carry fewer RVUs than a laparotomy.
2. Given the multiple abdominal procedures performed, it is correctly assumed that the retroperitoneal exploration would occur through the same incision at the same time. However, should a retroperitoneal exploration be performed at a separate time and/or through a separate incision as an intraperitoneal procedure, appropriate documentation and modifiers can provide justification for the additional payment.
3. 44139 is an “add-on” code that can only be reported with codes 44140-44147 and needs no modifier when so reported.
4. It is extremely rare that suturing a mesenteric tear would ever be billable, given that it must be a “separate procedure” for it to be billable. It can only be billed if no other abdominal procedure is being performed at the same time (such as in a patient with an already open abdomen who happens to have a mesenteric tear and no other abdominal procedures are performed at that time on the patient).
5. It is not clear why a modifier is not required for a central line performed at the same time as other procedures, while an arterial line insertion does require a modifier.
6. As a laparotomy incision is at least 25 cm long in most adults and when left open, is well more than 2 cm wide, 50 cm² is clearly more appropriate than 97605.
7. Foley catheterization at the same time as the major procedures identified (such as the bowel resections) is not separately billable. Typically, this means that the catheterization is performed in the OR immediately before the laparotomy.  However, if the Foley catheter was placed as a component of the patient’s initial assessment in the Trauma Bay (as is often the case), it is separately billable and requires a modifier 59 to indicate that it was a separate procedure performed at a different time and location than the abdominal operation.  Alternatively, even if the Foley is placed in the OR but is a much more difficult insertion (and documented as such) a 22 modifier (Difficult procedure) can be used to justify a separate payment.

Subsequent Operation (See Table 2):

Comments:

1. This is the solution Dr. Esposito selected for the four enteroenteric anastomoses. One code requires a 58 modifier only (because it is a staged procedure following the initial operation.  The other 3 anastomoses require a 59 modifier to indicate that separate additional procedures were performed as well as the 58 modifier.  There is a possibility for this solution to be denied because 44130 is labelled as a “separate procedure”, which is why the 59 modifier is applied to 3 of the 4 anastomoses.  However there have been audits of cases with multiple uses of 59 modifiers.
2. The bowel resection procedures performed at the initial operation were coded as 44120 and 44121 with the 52 modifier for a reduced payment due to the anastomosis not having been completed. For the completion procedure, the same codes should be used, with the 58 modifier indicating that these are performed as related, staged procedures.  This strategy for abdominal damage control surgery was advocated by the Bulletin of the American College of Surgeons.⁴  For the colonic anastomosis, the completion would be 44140 with the 58 modifier.  However, Dr. Esposito’s use of multiples of 44130 is reasonable and could potentially generate more revenue, in large part because of the horrible and inconsistent valuation of the additional resection and anastomosis code (44121) at only 4.4 wRVUs per resection and anastomosis.  This contrasts with the 44120, 44130, and the 44140 resection and anastomosis codes all carry at least 20 wRVUs each.  Of course, the rationale is that the primary resection & anastomosis codes are supposed to include the RVUs for the laparotomy (i.e., opening & closing the abdomen), which becomes very problematic in the first place when multiple simultaneous procedures are being performed, each one of which is supposed to include the payment for the laparotomy.
3. Removal of the bullet is coded as 49402 (“Removal of peritoneal foreign body from peritoneal cavity”). There is no CCI conflict between 49402 and any of the bowel anastomosis codes (i.e., 44120, 44121, 44130, or 44140 during the same operation, so I reject Dr. Esposito’s claim that this is not billable.  I suspect that this stems from the fact that there is a conflict between 49402 and the laparotomy codes (49000 and 49002). 49402 cannot be billed with 49000 at all (that is, even with the use of modifiers), but it can be billed with 49002 if a modifier is applied.  However, because neither 49000 or 49002 themselves can be used due to conflicts with the primary operative codes of intestinal resection and anastomoses, the conflicts between the peritoneal foreign body removal and the laparotomy codes are not relevant.
4. A hernia repair code cannot be applied to the midline laparotomy incision. However, if there are fascial defects in the flanks from the bullet’s penetration, then a hernia code can be applied.  Again, thorough documentation should detail the nature, location, and repair techniques for the hernia procedure(s).   If there are bilateral ventral hernias, then the “RT” and “LT” modifiers should be applied to the repair code for each side.