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Avoid Payer Audits with Year 2022 General Surgery Coding Guidelines


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General surgery receives maximum external payer audit requests due to inaccurate coding. To avoid such external payer audits we shared general surgery coding guidelines and referred Medicare NCCI 2022 Coding Policy Manual: Chapter 1. Let’s discuss HCPCS/CPT code-defined procedures include services that are integral to them. Some of these integral services have specific CPT codes for reporting the service when not performed as an integral part of another procedure.

For example, CPT code 36000 i.e., introduction of needle or intracatheter, the vein is integral to all nuclear medicine procedures requiring the injection of a radiopharmaceutical into a vein. CPT code 36000 is not separately reportable with these types of nuclear medicine procedures. However, CPT code 36000 may be reported alone if the only service provided is the introduction of a needle into a vein. Other integral services do not have specific CPT codes. For example, wound irrigation is integral to the treatment of all wounds and does not have an HCPCS/CPT code.

Services integral to HCPCS/CPT code-defined procedures are included in those procedures based upon the standards of medical/surgical practice. It is inappropriate to separately report services that are integral to another procedure with that procedure.

Some of the surgical examples are as follows:

  • Because a myringotomy requires access to the tympanic membrane through the external auditory canal, removal of impacted cerumen from the external auditory canal is not separately reportable.
  • A “scout” bronchoscopy to assess the surgical field, anatomic landmarks, the extent of disease, etc., is not separately reportable with an open pulmonary procedure such as a pulmonary lobectomy. By contrast, an initial diagnostic bronchoscopy is separately reportable. If the diagnostic bronchoscopy is performed at the same patient encounter as the open pulmonary procedure and does not duplicate an earlier diagnostic bronchoscopy by the same or another physician, the diagnostic bronchoscopy may be reported with modifier 58 appended to the open pulmonary procedure code to indicate a staged procedure. A cursory examination of the upper airway during bronchoscopy with the bronchoscope shall not be reported separately as a laryngoscopy. However, separate endoscopies of anatomically distinct areas with different endoscopes may be reported separately (e.g., thoracoscopy and mediastinoscopy).
  • If an endoscopic procedure is performed at the same patient encounter as a nonendoscopic procedure to ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic procedure is not separately reportable with the nonendoscopic procedure.
  • Because a colectomy requires exposure of the colon, the laparotomy and adhesiolysis to expose the colon are not separately reportable.

Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often an overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work. The component elements of the pre-procedure and post-procedure work for each procedure are included component services of that procedure as a standard of medical/surgical practice.

Some general guidelines are as follows:

  • Many invasive procedures require vascular and/or airway access. The work associated with obtaining the required access is included in the pre-procedure or intra-procedure work. The work associated with returning a patient to the appropriate post-procedure state is included in the post-procedure work.
  • Medicare Anesthesia Rules prevent separate payment for anesthesia services by the same physician performing a surgical or medical procedure. The physician performing a surgical or medical procedure shall not report CPT codes 96360-96377 for the administration of anesthetic agents during the procedure. If it is medically reasonable and necessary that a separate provider/supplier (anesthesia practitioner) perform anesthesia services (e.g., monitored anesthesia care) for a surgical or medical procedure, a separate anesthesia service may be reported by the second provider/supplier. When anesthesia services are not separately reportable, providers/suppliers shall not unbundle components of anesthesia and report them in lieu of an anesthesia code.
  • If an endoscopic procedure is performed at the same patient encounter as a nonendoscopic procedure to ensure that no intraoperative injury occurred or to verify that the procedure was performed correctly, the endoscopic procedure is not separately reportable with the non-endoscopic procedure.
  • Many procedures require cardiopulmonary monitoring, either by the physician performing the procedure or an anesthesia practitioner. Since these services are integral to the procedure, they are not separately reportable. Examples of these services include cardiac monitoring, pulse oximetry, and ventilation management.
  • Exposure and exploration of the surgical field is integral to an operative procedure and is not separately reportable. For example, an exploratory laparotomy (CPT code 49000) is not separately reportable with an intra-abdominal procedure. If exploration of the surgical field results in additional procedures other than the primary procedure, the additional procedures may generally be reported separately. However, a procedure designated by the CPT code descriptor as a ‘separate procedure’ is not separately reportable if performed in a region anatomically related to the other procedure(s) through the same skin incision, orifice, or surgical approach.
  • If a definitive surgical procedure requires access through diseased tissue (e.g., necrotic skin, abscess, hematoma, seroma), a separate service for this access (e.g., debridement, incision, and drainage) is not separately reportable. Types of procedures to which this principle applies include, but are not limited to, -ectomy, -otomy, excision, resection, -plasty, insertion, revision, replacement, relocation, removal, or closure. For example, debridement of skin and subcutaneous tissue at the site of an abdominal incision made to perform an intra-abdominal procedure is not separately reportable.
  • If removal, destruction, or other forms of elimination of a lesion requires coincidental elimination of other pathology, only the primary procedure may be reported. For example, if an area of the pilonidal disease contains an abscess, incision, and drainage of the abscess during the procedure to excise the area of pilonidal disease is not separately reportable.
  • An excision and removal (-ectomy) include the incision and opening (-otomy) of the organ. An HCPCS/CPT code for an –otomy procedure shall not be reported with an –ectomy code for the same organ.
  • Multiple approaches to the same procedure are mutually exclusive of one another and shall not be reported separately. For example, both a vaginal hysterectomy and an abdominal hysterectomy shall not be reported separately.
  • If a procedure using one approach fails and is converted to a procedure using a different approach, only the completed procedure may be reported. For example, if a laparoscopic hysterectomy is converted to an open hysterectomy, only the open hysterectomy procedure code may be reported.
  • If a laparoscopic procedure fails and is converted to an open procedure, the physician shall not report a diagnostic laparoscopy in lieu of the failed laparoscopic procedure. For example, if a laparoscopic cholecystectomy is converted to an open cholecystectomy, the physician shall not report the failed laparoscopic cholecystectomy nor a diagnostic laparoscopy.
  • If a diagnostic endoscopy is the basis for and precedes an open procedure, the diagnostic endoscopy may be reported with modifier 58 appended to the open procedure code. However, the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy. A scout endoscopy to assess anatomic landmarks and extent of disease is not separately reportable with an open procedure. When an endoscopic procedure fails and is converted to another surgical procedure, only the completed surgical procedure may be reported. The endoscopic procedure is not separately reportable with the completed surgical procedure.
  • Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure. Additionally, the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of surgery to treat complications that do not require a return to the operating room. Thus, treatment of a complication of a primary surgical procedure is not separately reportable:
  1. if it represents usual and necessary care in the operating room during the procedure; or
  2. if it occurs postoperatively and does not require a return to the operating room. For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We shared the year 2022 general surgery coding guidelines for provider education and referred Medicare NCCI 2022 Coding Policy Manual: Chapter 1. For any assistance needed for general surgery medical coding, email us at: info@medicalbillersandcoders.com or call us: 888-357-3226.

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