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CPT coding for hepatobiliary surgery

This column identifies several frequently asked questions about coding for liver surgery and the correct coding responses.

Christopher Senkowski, MD, FACS, Jayme Lieberman, MD, FACS, Jan Nagle, MS

October 1, 2018

Correct coding for Current Procedural Terminology (CPT)* requires attention to the nuances of the CPT code descriptors and payor reporting rules such as the Medicare National Correct Coding Initiative (NCCI) and Centers for Medicare & Medicaid Services (CMS) Medically Unlikely Edits (MUE) policies. This column lists several frequently asked questions about coding for liver surgery and the correct coding responses.

Is there a limit to how many units may be reported for CPT code 47120, Hepatectomy, resection of liver; partial lobectomy, for a single operative session? Segments III, V, and VII are in completely different locations; however, our coders told me this is an unlikely event per CMS coding rules, and only resection of two segments may be reported. Also, when multiple segmentectomies are performed in different areas of the liver, should 47120 be reported with modifier 51, Multiple procedures, or 59, Distinct procedural service?

The liver is divided into eight functional segments based on the Couinaud classification. The delineation of the segments is based on the fact that each segment has its own dual vascular inflow, biliary drainage, and lymphatic drainage. Segment I is the caudate lobe. Segments II through VIII are numbered in clockwise fashion, starting superiorly in the left hemiliver. Segments II, III, and IV compromise the left lobe of the liver. Segments V, VI, VII, and VIII comprise the right lobe of the liver. Therefore, for the scenario in the question, resection of segment III in the left lobe and resection of segments V and VII in the right lobe is reported as 47120, 47120-59. Appending modifier 59 indicates a distinct separate service, but to be perfectly clear to a payor, a narrative or some documentation such as the operative report should also be submitted that clearly indicates segmentectomies were performed on both the right and left lobes of the liver. Furthermore, the CMS MUE policy for reporting 47120 is two units or two “lobes.” This does not recognize the rare situation where part of the right, part of the left, and the caudate lobes are resected, which should allow for three units of 47120.

Coding tip: Code 47120 does not allow use of modifier 50, Bilateral procedure. Therefore, it would be incorrect to report 47120-50 or 47120-RT and 47120-LT for partial lobectomies of both the right and left lobes.

How do you code multiple segmentectomies and wedge resections from the same lobe of the liver?

A partial lobectomy (single or multiple segmentectomies in one lobe) is reported with 47120. A smaller wedge resection is reported with code 47100, Biopsy of liver, wedge. The difference between a segmentectomy and a wedge resection is determined by the surgeon. If, for example, two segmentectomies and a single wedge resection were performed on the right lobe of the liver, you would report 47120, 47100-59. Modifier 59 is required instead of modifier 51 because there is a NCCI edit for the code pair 47120/47100. Modifier 59 would indicate that the wedge resection was a distinct procedure. A single segment resection and two wedge resections from two different segments would be reported as 47120, 47100-59, 47100-59. However, multiple wedge resections (more than two) for multiple lesions (that is, metastatic disease) would have few indications and would rarely be performed.

If a laparoscopic distal pancreas and liver segmentectomy are performed in the same setting, what codes are reported, and is modifier 51 needed even if they are distinct services?

No existing code describes laparoscopic pancreatic or liver resection. Therefore, report code 47379, Unlisted laparoscopic procedure, liver (crosswalk fee to 47120), and code 48999, Unlisted procedure, pancreas (crosswalk fee to 48140). If this case involves a Medicare patient, it is not necessary to report modifier 51 because the Medicare claims processing system automatically assigns modifier 51 when appropriate. However, if the claim is submitted to a non-Medicare payor, then you may append modifier 51 to code 48999, which was crosswalked to the lower-valued code (48140), depending on payor preference.

A central hepatectomy (for example, resection of segments IV, V, and VIII) is a very complex operation. How is this reported?

Segments V and VIII are part of the right lobe of the liver. Segment IV is considered the medial part of the left lobe of the liver. A partial lobectomy (for example, single or multiple segmentectomies in one lobe) is reported with 47120. If segments IV, V, and VIII were resected, you would report 47120, 47120-51 or 47120, 47120-59, depending on payor preference. Understanding that this is a complex operation in terms of time and intensity, modifier 22, Increased procedural services, may also be appended. However, documentation should be submitted to support the substantial additional work and the reason for the additional work (increased intensity, time, technical difficulty of procedure, severity of the patient’s condition, physical and mental effort required). In addition, biliary reconstruction, if performed, would be reported separately.

How do I report an extended right hepatic lobectomy?

An extended right hepatic lobectomy is the removal of the true right lobe (segments V–VIII) of the liver in continuity with most or all of the medial segment of the left lobe (segment IV). This operation would correctly be reported with code 47122, Hepatectomy, resection of liver; trisegmentectomy. Code 47122 also is reported for a left trisegmentectomy, which consists of the removal of the left liver lobe (segments II, III, and IV) along with the right anterior segments (V and VIII).

A patient undergoes a radical cholecystectomy for gallbladder mass due to concern for gallbladder adenocarcinoma. The cholecystectomy is performed with en bloc wedge removal of segment IVb/V to ensure an adequate margin around the gallbladder. How is this reported?

The patient had gallbladder cancer, and the gallbladder was removed as part of a liver resection (the more extensive procedure). The en bloc resection of the gallbladder with resection of the liver as previously described would be reported with one unit of 47120. Although segment IVb is in the left lobe and segment V is in the right lobe, this is essentially one resection of one liver specimen.

How do I report a laparoscopic cholecystectomy and a laparoscopic unroofing of a liver cyst?

The laparoscopic cholecystectomy is reported with code 47562, Laparoscopy, surgical; cholecystectomy. There is no code to report laparoscopic unroofing of a liver cyst, and therefore code 47379, Unlisted laparoscopic procedure, liver, is reported (crosswalk fee to 47010, Hepatotomy, for open drainage of abscess or cyst, 1 or 2 stages). When reporting an unlisted code, documentation should be submitted that provides pertinent information, including an adequate definition or description of the procedure and the time, effort, and equipment necessary to provide the service.

While performing a laparoscopic cholecystectomy for cholecystitis, the surgeon noted a “fatty liver” and took a biopsy of the liver. Can we report both procedures?

Yes, you would report both procedures. The laparoscopic cholecystectomy is reported with code 47562. The liver biopsy is reported with add-on code 47001, Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for primary procedure). Code 47001 does not indicate open or laparoscopic; however, because this is an add-on code, the intraoperative work would be the same, and therefore code 47001 would be reported when performed via either approach.

When I perform ablation of a liver lesion, I use microwave therapy, not radiofrequency or cryoablation. What code should I report?

Microwave is part of the radiofrequency spectrum and simply uses a different part of the radiofrequency spectrum to develop heat energy to destroy abnormal tissue.§ Therefore, code 47370, Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency, should be reported for this procedure.

Learn more

Learn more about correct coding at an American College of Surgeons (ACS) General Surgery Coding Workshop. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. Find out more and register for a workshop on the ACS website. The 2019 workshop dates and locations will be posted to the ACS website in December.

*All specific references to CPT codes and descriptions are © 2017 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Centers for Medicare & Medicaid Services. National correct coding initiative edits. Available at: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Accessed August 23, 2018.

Fortin F, Jones J. Couinaud classification of hepatic segments. Radiopaedia.com. Available at: https://radiopaedia.org/articles/couinaud-classification-of-hepatic-segments. Accessed July 30, 2018.

§American Medical Association. Clinical Examples in Radiology. 2012;8(3). [Subscription required for viewing.]