For the fourth article highlighting tips from the National Correct Coding Initiative (NCCI) Policy Manual, the focus will be on guidance published in Chapter 6, Surgery: Digestive System. This chapter focuses on the CPT codes in the 40000-49999 range. However, as these articles provide just a few highlights from each chapter, you may wish to refer to Chapter 6 of the NCCI manual for additional and more complete information.
As a reminder, start by following the CPT guidelines, information within the code descriptors and parenthetical notes. For facility reporting on behalf of Medicare beneficiaries refer to the NCCI Policy Manual for Medicare, which can be found on the Centers for Medicare and Medicaid Services (CMS) website at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.
It is important to report the HCPCS/CPT code that most accurately describes the procedure performed. It is not appropriate to report a code if all of the services described by that code are not performed. Unbundling occurs when multiple codes are reported in place of a single HCPCS/CPT code that describes all of the services.
Many of the concepts pertaining to endoscopic and arthroscopic procedures have been covered in previous articles. However, the following is guidance to keep in mind when coding endoscopic digestive system procedures.
- The percutaneous placement of a therapeutic device, such as a G-tube, includes the subsequent removal of the tube when performed non-endoscopically. However, if for some reason the removal cannot be performed via a non-endoscopic procedure, and must be removed endoscopically, it is appropriate to assign a code for the endoscopic removal.
- If multiple endoscopic procedures are performed, only the more extensive procedure may be reported. For example, if a complete sigmoidoscopy is performed followed by a colonoscopy during the same encounter, only the colonoscopy may be reported.
- If during an endoscopy the larynx is visualized using an esophagoscope or upper gastrointestinal endoscope, it is not appropriate to additionally report a code for a laryngoscopy. However, if a laryngoscopy is additionally performed via a separate laryngoscope, both the laryngoscopy and esophagoscopy, or upper gastro-intestinal endoscopy) may be reported with the appropriate modifiers.
- CPT code 76000, Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time, is an integral component of all endoscopic (and laparoscopic) procedures and may not be separately reported.
- Exploratory laparotomy, CPT code 49000, Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure), may not be separately reported with another open abdominal procedure.
- A cholecystectomy is included in hepatectomy procedures represented by CPT code ranges 47120-47130, and 47133-47172, and may not be separately reported. The same guidance pertains to a Whipple-type pancreatectomy (CPT code range 48140-48154), which also includes the removal of the gallbladder.
- When an incidental appendectomy of a normal appendix is performed during another abdominal procedure, the appendectomy may not be separately reprted.
- When a hernia is repaired at the site of an incision of an open or laparoscopic abdominal procedure, the hernia repair may not be separately reported. In addition, incidental hernia repairs are also not separately reportable. However, if a medically necessary hernia is repaired at a site other than the incision, it may be additionally reported.
- A panniculectomy is not separately reportable when removing excessive skin and subcutaneous tissue at the site of an abdominal incision, this includes hernia repair. However, when a more extensive abdominoplasty is performed, CPT code 15830, Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy, may be separately reported.
- If during a procedure on the small or large intestine, an iatrogenic laceration or perforation occurs, the repair of the laceration/perforation may not be separately reported.
- During a procedure to close a fistula, if the excision of a portion of an organ through which the fistula passes is required, the excision of the tissue may not be separately reported.
- “Washing,” infusion, and/or removal of fluid from the body cavity are included in a diagnostic laparoscopy. Therefore, it is not appropriate to report abdominal paracentesis or peritoneal lavage with a diagnostic or surgical laparoscopic procedure.
- It is not appropriate to report CPT code 49400, Injection of air or contrast into peritoneal cavity (separate procedure), with laparoscopic procedures as the injection of air into the abdominal or pelvic cavity is inherent to many laparoscopic procedures.
- It is not appropriate to report laparoscopic paraesophageal hernia repair with fundoplasty codes (43281-82) for a figure-of-eight suture often performed during gastric restrictive procedures.
Below are a few questions and answers to illustrate this guidance:
A patient with a right inguinal hernia presented for laparoscopic repair. After the hernia was identified, tense ascites was noted within the hernia sac. The sac was opened and 5 liters of ascites was aspirated. Is it appropriate to report CPT code 49082 in addition to the laparoscopic hernia repair code when paracentesis is performed to drain fluid from the hernia sac?
It is not appropriate to additionally report CPT code 49082, Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance, with a laparoscopic hernia repair. Abdominal paracentesis or peritoneal lavage is not separately reported with a diagnostic or surgical laparoscopic procedure.
A patient with abdominal pain and rectal bleeding presented for a colonoscopy. The colonoscope was introduced and advanced to the cecum. During the procedure, moderate-sized internal hemorrhoids were noted in the rectum. It was decided to perform a separate sigmoidoscopy to ligate the hemorrhoids following the colonoscopy during the same encounter. What is the appropriate CPT code when a colonoscopy and sigmoidoscopy are performed during the same encounter?
Report CPT code 45398, Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids), for the colonoscopy and sigmoidoscopy with ligation of hemorrhoid procedure performed. According to the guidance in the NCCI manual “Only the more extensive endoscopic procedure may be reported for a patient encounter. For example, if a sigmoidoscopy is completed and the physician also performs a colonoscopy during the same patient encounter, only the colonoscopy may be reported.” Therefore, it would be inappropriate to assign a separate CPT code for the flexible sigmoidoscopy.
A patient with appendicitis was taken to the operating room for a laparoscopic appendectomy. An intraumbilical incision was made and an incarcerated umbilical hernia was identified. The hernia contents were reduced before proceeding with the intended laparoscopic appendectomy. When an incarcerated hernia is repaired with another abdominal procedure is it appropriate to assign a separate code for the laparoscopic hernia repair?
It is not appropriate to additionally report a hernia repair when performed through the same incision as the appendectomy. When a hernia is repaired at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair may not be separately reported. In addition, incidental hernia repairs are also not separately reportable. The fact that the hernia was incarcerated does not affect code assignment.