It is often challenging to assign a correct Current Procedural Terminology (CPT)* code to unusual procedures and services. This column responds to several frequently asked questions posed to the American College of Surgeons’ Coding Hotline.
What codes are reported for laparoscopic takedown and repair of an ileosigmoid fistula, ileocolic resection, creation of loop ileostomy, and intraoperative sigmoidoscopy?
This procedure would be reported with codes 44205, Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy, and 44187, Laparoscopy, surgical; ileostomy or jejunostomy, non-tube. It would be incorrect to report the intraoperative sigmoidoscopy, which may be performed to check the anastomosis.
During the approach of a sigmoidectomy procedure, the surgeon encounters an abdominal abscess. He “unroofs” the abscess and continues to complete the sigmoidectomy. Can he report 49020, Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open, for the unroofing procedure?
Code 49020 specifies drainage of an abscess. If the surgeon only opened (unroofed) the abscess, code 49020 should not be separately reported in addition to the sigmoidectomy procedure code. If the unroofing work was significant, modifier 22, Increased procedure services, may be appended to the sigmoidectomy procedure code. Documentation must support the substantial additional work and the reason for it (that is, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required).
The surgeon used a falciform ligament flap to reinforce the pancreatic jejunal anastomosis when performing a Whipple procedure. How would the flap be reported?
There is no code to report this procedure, and it would be difficult to find a code to crosswalk a value to if an unlisted code were reported. The best option would be to append modifier 22 to the primary procedure and document the additional work and time compared with the typical time for a Whipple procedure (for example, 25 percent more operative time). Documentation must support the substantial additional work and the reason for the additional work (that is, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required).
How do you report a sigmoid resection, left descending colostomy, and repair of an inguinal hernia?
Report both code 44143, Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure), and code 49505, Repair initial inguinal hernia, age 5 years or older; reducible.
A patient with an elevated prostate-specific antigen undergoing prostate biopsy had a rectal stricture treated by anal dilation before an ultrasound probe and needle to perform the biopsy were inserted. Is it appropriate to report CPT codes for both the dilation of the rectal stricture and the prostate biopsy?
No, only report code 55700, Biopsy, prostate; needle or punch, single or multiple, any approach. Code 55700 includes dilation of the anus, and therefore, it would be inappropriate to report code 45905, Dilation of anal sphincter (separate procedure) under anesthesia other than local or code 45910, Dilation of rectal stricture (separate procedure) under anesthesia other than local. Codes 45905 and 45910 are both designated as a “separate procedure,” which means the procedure is carried out as an integral component of the total procedure. To report a code with a “separate procedure” designation, the procedure must be considered unrelated to or distinct from other procedures performed at the same time.
How do I report laparoscopic repair of an internal hernia in the small intestine?
The correct code to report is 44238, Unlisted laparoscopy procedure, intestine (except rectum), although some payors may accept or require reporting 44799, Unlisted procedure, small intestine, or code 49659, Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy. When reporting an unlisted code to describe a procedure, it is necessary to submit supporting documentation with the claim to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.
The surgeon performed a laparoscopic repair of a strangulated ventral hernia and a laparoscopic repair of an inguinal hernia on the same day. Can the surgeon bill for both procedures?
Yes, both procedures can be reported with codes 49653, Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated, and 49650, Laparoscopy, surgical; repair initial inguinal hernia. Because this code pair does not have a National Correct Coding Initiative edit, modifier 51, Multiple procedures, would be appended to the lower-valued code as follows: 49653, 49650-51.
ACS Fellows can call the Coding Hotline for answers to questions related to CPT; Healthcare Common Procedure Coding System; International Classification of Diseases, 10th Revision Clinical Modification codes; and global fee periods. To contact a coding specialist, call 800-ACS-7911 (800-227-7911), 8:00 am to 5:00 pm Central time, Monday through Friday, excluding holidays and weekends.
*All specific references to CPT codes and descriptions are © 2018 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.
