Coding Op*ons for Reopera*ve Procedures. ASMBS Reopera*ve Surgery Insurance Toolkit

Transcription

1 Coding Op*ons for Reopera*ve Procedures ASMBS Reopera*ve Surgery Insurance Toolkit

2 Disclaimer While these are general guidelines, your par*cular region/insurance carrier may require alternate coding.

3 Add-on codes Enterolysis - CPT Generally included with any procedure Few excep*ons Unless it is the primary (and usually only) procedure 22 modifier Increased Procedural Service requiring work substan*ally greater than typically required. Used denote a case where substan*ally more work than usual is required. Should be used for less than 10% of cases. Detailed documenta*on of why the case was longer/more difficult is required in either a separate document or within the opera*ve report Carriers may have specific policy and procedure for use of -22 modifier Even if properly coded and documented may not get paid Concomitant EGD (CPT wrvu-2.39) Excluded by Medicare on many cases When billed to Medicare - Should be used for diagnosis rather than confirma*on of opera*ve comple*on to be paid

4 Use of Open Codes for Laparoscopic Cases Generally not acceptable unless agreed upon by the provider and the carrier Unlisted codes are problema*c for payment Best strategy for reimbursement Precert unlisted if needed Offer comparable open codes in wri*ng to the carrier at precer*fica*on Carefully read the policy for instruc*ons on how to bill certain procedures Try to get pre-op agreement on valua*on of the unlisted code pre-op. It is customary for CPT commicee to value Open and Laparoscopic codes the same to avoid and economic incen*ve for procedure approach

5 Hiatal Hernia Hiatal Cruralplasty- Generally considered incidental to the all primary bariatric surgery codes of all types Because of the above, will oeen not be paid when billed with reopera*ve procedures, unless the procedure is a hiatal hernia repair Less common coded with (wrvu min) Laparoscopic paraesophageal hernia repair and (wrvu min) with mesh could be used Again with the 52 modifier

6 Components of The descrip*on of this code includes The physician reduces the herniated stomach into the abdomen and dissects the hernia sac and gastroesophageal fat pad using a combina*on of sharp and blunt dissec*on. While significant paraesophageal hernias do occur in bariatric surgery, they represent a small minority (up to perhaps 8-10%). When true paraesophageal hernias occur, can be billed with all bariatric procedures in the current CCI edit. See more at: hcp://asmbs.org/2013/05/insurancecommicee-coding-alert-cpt laparoscopicfundoplasty/#sthash.3fma9xlm.dpuf

7 Billing Hiatal Hernia Examples of Anatomy requiring CPT 43281

8 Adjustable Gastric Band Generally the easiest to code revisions The codes already exist The procedures are easy to standardize Codes were included in the original CPT submission process. Available codes: Placement of AGB and Port wrvu Revision AGB band component only wrvu Removal of AGB Band component only WRVU Remove and replace AGB Band component only wrvu Removal of AGB band and port wrvu 15.79

9 Typical Secondary Opera*ons Slip/concentric dila*on/band reposi*oning All involve revision of the band component alone without need for port revision ( 104 min) Erosion (band or tubing or both) Removal of AGB band and port wrvu Can also be coded with closure of bowel perfora*on if needed ( ) Tubing issues for revision (tubing shortening tubing leakage) for removal (tubing erosion) Port problems Revision port flip Removal early port infec*on Removal and replacement (leakage in the port Lap-Band,any port issue with the realize band) Band leak For band replacement For Removal 43772

10 Conversions Band to Bypass Removal of AGB and Port CPT (wrvu 16.76) Lap Gastric Bypass CPT 43644/5 (wrvu 29.4/31.5) lysis of adhesions is incidental to these procedures Band to Sleeve Removal of AGB and Port CPT (wrvu 16.76) Lap Sleeve Gastrectomy CPT (wrvu 22) Sleeve to Bypass Lap Gastric Bypass CPT 43644/5 (wrvu 29.4/31.5) Consider 22 modifier if case length greater than 150 min

11 Gastric Bypass Revision Codes Current available codes truncal vagotomy laparoscopic wrvu Revision of gastric restric*ve procedure open wrvu Revision of Gastro-Jejunal anastomosis open wrvu enterectomy single with

12 Gastric Bypass Revision Codes each addi*onal enterectomy and anastomosis wrvu enterectomy laparoscopic wrvu reduc*on of volvulus, intussuscep*ons, internal hernia open wrvu Enterolysis, laparoscopic wrvu unlisted stomach wrvu - 0

13 Bypass Some scenarios Anastomo*c revision Common Indica*ons Stricture, Dila*on, Chronic Ulcera*on Coding (wrvu 27.89) if open, Lap Pouch revision Common Indica*ons: Downsize, Fistula Coding open wrvu (80 min), Lap Internal hernia repair Open (15.52 wrvu) Laparoscopic (15.27 wrvu) Jejunal limb revision, Conversion to long limb open (poss addi*onal 44121) wrvu 20.82, 4.44 Laparoscopic (wrvu 23.39) possible mul*ple instances Placement of G-tube Open (w RVU min) Lap (wrvu min)

14 Sleeve Currently available codes Longitudinal Gastrectomy wrvu min No specific reopera*ve codes available

15 Gastric Sleeve Revisions Sleeve to bypass Laparoscopic Gastric Bypass wrvu Could use the 22 modifier with care re-sleeve sleeve gastrectomy code May need 22 if very long/hard Or 52 if easier as one component of the procedure (greater curve mobiliza*on) is omiced unlisted always safe Strictureplasty there is no comparable procedure in intent or conduct.

16 Summary Coding and reimbursement for reopera*ve bariatric surgery is as complicated as the procedures themselves Do Use the right code or unlisted Be proac*ve for reimbursement Follow up billing and be prepared to file on paper Don t Be misleading Use open codes for laparoscopic opera*ons Expect all cases to be paid easily