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General Surgery Coding Guidance for 2009 Additions and Revisions

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While ASC facilities can expect a reduction in reimbursement in the specialties of pain management and GI in 2009, general surgery sees several procedures new to CPT and also some to the Medicare-approved procedures list which may offer reimbursement opportunities. Here is an analysis of these coding changes in three areas of general surgery and best practices to ensure you code and continue to code correctly these procedures.


1. Integumentary
There are revisions to the integumentary add-on procedures and a revision to a series of procedures that surgery centers should note.

▪ +11001 — Debridement of extensive eczematous or infected skin; each additional 10% body surface, or part thereof (revised)
▪ +11201 — Removal of skin tags, each additional 10 lesions or part thereof (revised)
▪ +11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct color defect of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (revised)

The phrase “or part thereof” was added to several add-on codes as well as those above to clarify the prior CPT verbiage. These revisions offer clarification regarding the reporting for repairs over the initial measurement regardless if over by a percentage, number of lesions, or area of measurement.

The revised add-on codes are intended to include repair of any additional percentage or part within the measurement provided.

Remember: Add-on codes cannot stand alone and should be reported in conjunction with a primary code for the surgical procedure performed.

▪ 12031-12057 — Repair, intermediate, wounds of…… (revised)

The prior reference in these codes to “layer closure” and prior absence of “intermediate repair” verbiage led to confusion. This intermediate code series was revised to describe “intermediate” wound repair for consistency with “simple” and “complex” repair code verbiage to include “simple” or “complex” within CPT code descriptors.

Clinical documentation should detail the intermediate repair and specify anatomic sites being repaired. Coding guidelines stipulate that when multiple repairs are performed, the lengths of those in the same classification and from all anatomic sites that are grouped together into the same CPT descriptor may be added together. CPT provides extensive reporting guidelines for Repair/Closures.

2. Anal
A new CPT code, and one that is new to the Medicare-approved procedures list (but typically considered an office-based procedure) is 46930Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency).

This was newly established to report various thermal energy procedures for hemorrhoids including but not limited to infrared coagulation, cautery, radiofrequency.

CPT codes 49634–46936 are deleted in 2009 since they were considered redundant and do not represent multiple hemorrhoid destruction.

Note that non-thermal energy procedures should not be reported with 46930. Rather, a parenthetical note has been added following CPT 46930 directing us to the appropriate codes for reporting the different methods of hemorrhoid destruction or removal.

While this is usually an office-based procedure, there are many facilities that do these types of cases (hemorrhoidectomies in general) even though the reimbursement is typically low — depending upon the CPT code — if doing so keeps a doctor at the facility. In addition, sometimes this procedure (hemorrhoidectomy/destruction) isn't the only procedure performed in the same operative session, so coders should know how to code the procedure to ensure the surgery center receives the reimbursement.

3. Abdomen, peritoneum and omentum
There are six new procedures pertaining to the abdomen, peritoneum and omentum that are particularly worth noting.

49652Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible
49653Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated
49654Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible
49655Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated
49656Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible
49657Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated

It is important to be aware of the following guidelines for these procedures when determining code selection.

  • CPT codes 49652-49657 are newly established and should be utilized for reporting laparoscopic hernia repairs specifically described for each code and not the open repair codes.
  • Since the CPT verbiage for codes 49652-49657 includes mesh insertion, when performed, mesh insertion as well as lysis of adhesions are not separately reported.
  • Documentation should specify the type of hernia (e.g. inguinal, ventral, incisional, etc.), technique (laparoscopic versus open), and whether reducible versus incarcerated or strangulated.
  • Diagnostic laparoscopy is inherent to surgical services included in these new codes.
  • Add-on code +49568 is revised in 2009, adding the word open to its CPT verbiage. It cannot be reported for the newly added laparoscopic incisional or ventral hernia repairs.


Other issues to consider
Keep in mind that while procedures considered “office-based procedures” offer reimbursement at the office surgery rate, your surgeon should know the facility will receive some form of reimbursement for these procedure as well as other newly added procedures. The knowledge and performance of newly added procedures such as laparoscopic hernia repairs to the Medicare-approved procedures list will go a long way toward increasing your volume and balancing the financial impact/decline from other specialties.

I would be remiss if I didn’t emphasize the importance of appropriate HCPCS code selection based on accurate and detailed clinical documentation. Your ASC coder should be very knowledgeable not only with respect to coding your facility’s routine surgical procedures but also the newly added procedures to CPT and the Medicare-approved procedures list.

Your ASC facility should complete its review of all AMA CPT 2009 changes with a thorough comparison and analysis of codes new to the Medicare-approved procedures list for 2009. Make sure to include an examination of additions, deletions and exclusions listings.

Ms. Bentin (This email address is being protected from spambots. You need JavaScript enabled to view it. ) is a principal with Coding Compliance Management, a consulting company specializing in coding support, reimbursement and training for ASCs and specialty hospitals. Learn more about CCM at www.ccmpro.com.

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