Correct Current Procedural Terminology (CPT®)* coding and documentation are important for seamless billing. This article provides several frequently asked questions and the correct coding responses, along with documentation tips to reduce denials.
Q: I just started doing robotic eTEP (extended totally extraperitoneal) hernia repairs. How should this be reported?
A: The anterior abdominal hernia repair codes are agnostic of approach. Laparoscopic, robotic, and open procedures are coded similarly. The CPT code to report should be chosen based on hernia size, presence of incarceration, and recurrent nature. If the work required was substantially greater than what is typically required, it may be appropriate to append modifier 22 to the procedure code. Documentation must be submitted that supports the substantial additional work and reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).
Q: Removal of an abdominal wall tumor resulted in a large defect. Would it be appropriate to report a hernia repair code along with other repair codes such as component separation, adjacent tissue transfer, and/or complex repair?
A: It would not be correct to report a hernia repair code for repair of an abdominal wall defect created either iatrogenically (e.g., removal of a tumor) or from trauma (e.g., stab wound). Such a repair is no different than repair for any other anatomic wound (e.g., repair after removal of a tumor from the thigh). The correct code to report would be based on the primary procedure and level of repair documented. For example, soft tissue tumor excision and exploration of a penetrating wound includes simple or intermediate repair. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision and not separately reported. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair, which may be reported separately if all the requirements for reporting complex repair are performed. Appreciable vessel exploration and/or neuroplasty also may be reported separately when performed. In addition, adjacent tissue transfer, flaps, and grafts may be reported separately when all the technical aspects of these closure procedures have been performed.
Q: Can you please provide clarification on how to measure an anterior abdominal hernia defect in order to select the appropriate hernia repair CPT code? CPT guidelines state that the measurement should be made “prior to opening the defect.” What is meant by opening the defect? The defect is already opened. Does this mean prior to repair? Does this mean prior to laparotomy or trocar placement? We want to ensure we are providing the correct measurement.
A: CPT instructions for measuring the total length of anterior abdominal hernia defect(s) states: “Hernia measurements are performed either in the transverse or craniocaudal dimension. The total length of the defect(s) corresponds to the maximum width or height of an oval drawn to encircle the outer perimeter of all repaired defects.” CPT also notes that “…the hernia defect size should be measured prior to opening the hernia defect(s) (i.e., during repair the fascia will typically retract creating a falsely elevated measurement).” This sentence was added by the CPT Panel to prevent hernia size inflation after manipulation of the fascia that may enlarge the defect. The goal is to accurately measure the fascial defect that requires repair prior to iatrogenic manipulation that may increase the defect size. In addition, it is important to state the defect size in the operative report For example, “Operation performed: ventral hernia repair of 7 cm hernia defect, measured prior to hernia opening,” or in an Addendum to the operative report such as: “Note: hernia size was measured as 7 cm prior to opening of the hernia defect.” Inconsistency between measurements without explanation (e.g., preoperative size that is not consistent with intraoperative size), failure to include a specific measurement in centimeters in the operative note, and/or failure to include a description of when and how that measurement was made could all lead to a denial by a payer. Coders and payers are looking for the “correct words.” This is not different than measuring and documenting in the operative note the size of a soft tissue tumor to select the correct code (e.g., less than or greater than 5 cm).
Q: We always get precertification for planned operations. What is the best advice for selecting an anterior abdominal hernia code for precertification?
A: Imaging or a physical exam can estimate the size of the hernia defect and determine if it is reducible or incarcerated/strangulated. However, at operation, it is possible that the size was underestimated. Therefore, it is important to get precertification for the possibilities of a larger size. For example, if the estimated hernia size is 5 cm, include hernia repair CPT codes for both 3–10 cm and greater than 10 cm in your precertification request.
Q: What is the appropriate code to report for a robotic-assisted laparoscopic excision of a retrorectal tailgut cyst?
A: There is no CPT code for the procedure performed robotically/laparoscopically. Therefore, you should report code 49329, Unlisted laparoscopy procedure, abdomen, peritoneum and omentum, and use the corresponding open procedure code 49215, Excision of presacral or sacrococcygeal tumor, as a proxy for charges.
Q: How is a median arcuate ligament release reported?
A: There is no specific CPT code for release of the median arcuate ligament. When exploration is performed with division of the diaphragmatic crura and associated compressive ligament, the surgeon may elect to use standard exploratory coding or defer to the unlisted procedure category. Open exploration of the abdomen through a midline or subcostal incision is described by code 49000, Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure), while open retroperitoneal exploration is reported with code 49010, Exploration, retroperitoneal area with or without biopsy(s) (separate procedure). Alternatively, a less-invasive laparoscopic exploration of the abdomen is reported with code 49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). CPT codes 49329, Unlisted laparoscopy procedure, abdomen, peritoneum and omentum, and 49999, Unlisted procedure, abdomen, peritoneum and omentum, are alternative reporting options. However, unlisted coding will require submission of medical records and be subject to review by a medical director. For more information, see www.jvascsurg.org/article/S0741-5214(10)02209-3/fulltext.
Q: How is laparoscopic takedown of a posterior fundoplication reported?
A: A laparoscopic takedown of a Toupet fundoplasty is reported with 43289, Unlisted laparoscopy procedure, esophagus.
Q: When a referring physician sends a patient to see me and sends his office notes, CBC and metabolic panel lab results, CT imaging with reports, what is counted as a “unique source” or “unique test” when considering how much data are analyzed for selection of a level of evaluation and management (E/M) code?
A: For the example above, review of the office notes from a single source would count as one “point” under Category 1 Tests and Documents for E/M code level selection. Review of each lab test and the CT report would each count as review of a unique test under the same category. If, in addition, you separately reviewed and interpreted the CT image (i.e., not just the report), this activity would meet the requirement for Category 2, Independent interpretation of test. Taken together, this work meets the criteria for extensive amount and/or complexity of data to be reviewed and analyzed, which is a high level of MDM.
Q: A surgeon performed ureterolysis to identify and protect the ureter during a total colectomy (44150) for extensive fibrosis and scarring due to an inflammatory response following recent bowel perforation. Medicare National Correct Coding Initiative (NCCI) edits indicate code 50715 is a component of code 44150, but this edit can be bypassed using an appropriate modifier. Can code 50715 be reported with modifier 59, Distinct procedural service, to bypass this edit?
A: Code 50715, Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis, may not be reported for the clinical scenario described in the question because the ureterolysis was necessary to identify the ureter which is part of the colectomy procedure. To report 50715 with 44150, the surgeon would have had to document that ureterolysis was performed because the ureters were trapped by the scar tissue, and therefore it was not incidental to the colectomy for identification. For example, obstruction symptoms were noted prior to surgery that is addressed during the same operative session as the colectomy procedure.
Q: A patient underwent debridement of a wound on the lower leg measuring 525 sq cm. We billed Medicare 11042 with one unit on one line and 11045 with 26 units on a second line. Medicare covered the claim for 11402 but denied payment for 11045 stating payment was not warranted for 26 units. Is there a different way to report this?
A: For this case, you would report 11042, 11045 x 12, 11045-XU x 12, and 11045-XU x 2. However, you will still likely need to do a reconsideration or higher-level appeal with the documentation supporting the number of units being billed. Chapter 1 of the Medicare NCCI General Coding Policy states that code 11045 has a Medically Unlikely Edit (MUE) of 12 units per day. Since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of CPT modifiers to report the same code on separate lines of a claim will enable a provider to report medically reasonable and necessary units of service in excess of an MUE value. Denials due to claim line MUEs or day of service (DOS) MUEs may be appealed to the local claims processing contractor. DOS MUEs are used for CPT codes where it would be extremely unlikely that more units of service than the MUE value would ever be performed on the same date of service for the same patient. If a CPT code has an MUE that is adjudicated as a claim line edit, appropriate use of CPT modifiers (i.e., 59 or -X[EPSU], 76, 77, 91, anatomic) may be used to report the same CPT code on separate lines of a claim. Each line of the claim with that CPT code will be separately adjudicated against the MUE value for that CPT code.
Q: A colorectal surgeon and urologist together performed a pelvic exenteration for gynecologic malignancy involving the colorectal system. The descriptor for code 58240 includes many instances of the terms with or without in reference to some subprocedures and the term with for other subprocedures. The surgeons did not perform bladder removal. Does this mean that a reduced services modifier should be appended to the code?
A: No, you do not need to append modifier -52 to 58240, Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof. In a total exenteration, the provider removes the uterus, tubes, ovaries, parametrial tissue, bladder, rectum, vagina, urethra, and part of the levator ani muscles. In an anterior exenteration, the provider does not remove the rectum. In a posterior exenteration, the provider does not remove the bladder and urethra or may resect a part of the anus, urethra, and part of the vulva. The phrase “or any combination thereof” at the end of code descriptor allows for the variation in work performed for pelvic exenteration.
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As part of the College’s ongoing efforts to help members and their practices submit clean claims and receive proper reimbursement, a coding consultation service—the ACS Coding Hotline—has been established for coding and billing questions. ACS members are offered five free consultation units (CUs) per calendar year. One CU is a period of up to 10 minutes of coding services time. Access the ACS Coding Hotline website at prsnetwork.com/acshotline.
Dr. Lieberman is a clinical assistant professor and vice-chair in the Department of Surgery at the Lehigh Valley Health Network Campus of the University of South Florida Morsani College of Medicine in Allentown, PA. He also is a member of the ACS General Surgery Coding and Reimbursement Committee and an ACS alternate advisor to the AMA CPT Editorial Panel.
