General Surgery Billing and Coding in 2019 – Key Considerations and Challenges

General Surgery Billing and Coding in 2019 – Key Considerations and Challenges

General surgery encompasses a wide range of surgical procedures—from gastrointestinal (GI) tract surgery, kidney, pancreas and liver transplantation, and thoracic and abdominal surgery to breast surgery and elective surgery. With many guidelines that impact code selection, general surgery medical billing and coding can be challenging. In 2019, general surgeons are dealing with 135 ICD-10 code changes and more than 69 CPT updates. Outsourcing medical billing to a company with expert coders and billers can help providers deal with current challenges and ensure accurate reimbursement.

 General Surgery 2019 CPT Code Changes

The CPT Code range for surgery includes codes for fine needle aspiration biopsy, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, hemic and lymphatic systems, mediastinum and diaphragm, digestive system, urinary system, male genital system, reproductive system and intersex, female genital system, maternity care and delivery, endocrine system, nervous system, eye and ocular adnexa, auditory system.

In 2019, there are extensive CPT codes changes for general surgery:

  • Fine Needle Aspiration (FNA) biopsy: The new CPT guidelines provide distinct definitions of FNA biopsy and core needle biopsy:
    • Fine needle aspiration (FNA) biopsyis performed when material is aspirated with a fine needle and the cells are examined cytologically
    • Core needle biopsyis typically performed with a larger bore needle to obtain core sample of tissue for histopathologic evaluation

New CPT codes for FNA

The 2019 FNA CPT code changes include 9 new codes (10004-10012), one deleted code (10022) and one revised code (10021).

Deleted: 10022    FNA biopsy with imaging

Revised: 10021    FNA biopsy without imaging, first lesion

 New:

  • FNA biopsy, withoutimaging guidance: 10021 first lesion and 10004 for each additional lesion
  • FNA biopsy, with ultrasoundguidance: 10005 first lesion and 10006 for each additional lesion
  • FNA biopsy, with fluoroscopicguidance: 10007 first lesion and 10008 for each additional lesion
  • FNA biopsy, with CTguidance: 10009 first lesion and 10010 for each additional lesion
  • FNA biopsy, with MRIguidance: 10011 first lesion and 10012 for each additional lesion

Add-on codes (e.g., +10004) should be listed separately after the primary procedure code (10021).

There are also new CPT guidelines for reporting FNA biopsy.

 

FNA documentation tips: To ensure accurate code assignment, the provider’s documentation must specify the following:

  • location of each lesion treated
  • complete description of each treated lesion
  • the guidance modality (ultrasound, fluoro, CT, MR) for each treated lesion
  • Medical necessity for every lesion treated
  • Skin Biopsy: In 2019, codes 11100 and 11101 have been deleted and replaced by6 new codes (11102–11107) for skin biopsy. The new codes, which are based on the thickness of the sample and the technique used, are as follows:

11102 Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette) single lesion
+ 11103 each separate/additional lesion (List separately in addition to code for primary procedure)
11104 Punch biopsy of skin (including simple closure, when performed) single lesion
+11105 each separate/additional lesion (List separately in addition to code for primary procedure
11106 incisional biopsy of skin (e.g., wedge) (including simple closure, when performed) single lesion
+11107 each separate/additional lesion (List separately in addition to code for primary procedure

 Points to note:

  • Codes 11102–11107 are reported when tissue is obtained exclusively for diagnostic histopathologic examination and is unrelated or distinct from other procedures/services provided in the same operative session.
  • The new skin biopsy code set defines three distinct biopsy modalities: tangential, punch, and incisional. For each, there is one code to report the initial biopsy, and a second code to report each additional biopsy.
  • Replacement of Gastronomy Tube: The code changes in this category include one deleted code and 2 new codes:

Deleted: 43760 (change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance)

New codes:

 43762  Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract

43763 Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; requiring revision of gastrostomy tract

Code 43762 should be used to report inadvertent G-tube removal (a common complication caused by a confused patient) or removal and replacementof a clogged tube. Code 43763 should be used to report more complicated G-tube replacement. Two examples of such complications are: when the tract is difficult to access, and requires dilation and guidewires to place a new tube or when there is maceration, ulceration, or necrosis of the surrounding skin (http://www.facsbulletin.com).

  • Inguinofemoral lymph node excision: Both superficial and deep node(s) are biopsied and/ or excised. The family of lymph node excision codes has got a new code in 2019:

 38531 biopsy or excision of lymph node(s); open, inguinofemoral node(s)

If the procedure is performed bilaterally, modifier 50, Bilateral procedure should be appended to 38531.

  • Sentinel lymph node mapping: CPT code 38900 is an add-on code that is used with any lymph node biopsy or lymphadenectomy codeto indicate the intraoperative work done to identify the sentinel lymph nodes. In 2019, the parenthetical following code 38900 has been revised to include codes for primary and staging pelvic and vulvar procedures to the current list of codes.

+38900, Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (list separately in addition to code for primary procedure)

38900 is reported in conjunction with 19302, 19307, 38500, 38510, 38520, 38525, 38530, 38531, 38542, 38562, 38564, 38570, 38571, 38572, 38740, 38745, 38760, 38765, 38770, 38780, 56630, 56631, 56632, 56633, 56634, 56637, 56640).

  • Catheter-assisted vein sclerotherapy:In 2019, there is a new code toreport catheter-directed sclerosant ablation using balloon isolation of an incompetent extremity vein:

New Category III code 0524T, Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring

This code includes all diagnostic imaging and imaging guidance performed in support of the procedure as well as monitoring of vascular access and catheter manipulation.

  • I&D of deep soft tissue abscess: As theAMA/RUC determined that code 20005 as potentially misvalued, it was deleted.

Deleted: Code 20005, Incision and drainage of soft tissue abscess, subfascial (i.e., involves the soft tissue below the deep fascia)

    • Lower extremity multi-layer compression: To prevent miscoding when using code 29581, Application of multi-layer compression system; leg (below knee), including ankle and foot, a parenthetical was added to the CPT code set that instructs not to report 29581 in conjunction with codes for treatment of incompetent veins for the same extremity. Code 29581 should also not be reported for simply wrapping the lower extremity with elastic bandages.
  • Appendix L-Vascular families: Appendix L has been updated to explain the order of vessels for arterial and venous vascular branching for catheterization procedures. As the aorta, vena cava, pulmonary artery, or portal vein are considered the starting point of catheterization in this approach, branches have been categorized into first, second, third order, and beyond.

Partnering with a medical billing and coding company specialized in general surgery coding can help surgeons report common general surgery procedures correctly. Expert coders and billers stay abreast with coding changes and can help providers improve claims management and reimbursement.

Thyroid Surgery – Frequently Asked Questions and Answers

Thyroid Surgery – Frequently Asked Questions and Answers

Thyroid surgery is a common procedure in which all or a portion of the thyroid gland is removed. Also known as thyroidectomy, this surgical procedure is used to treat several thyroid disorders such as cancer, non-cancerous enlargement of the thyroid (goiter) and overactive thyroid (hyperthyroidism). The thyroid is a butterfly-shaped endocrine gland located at the base of your neck, intricately placed right on top of the windpipe and next to the food pipe. The thyroid produces hormones that regulate every aspect of your metabolism (right from your heart rate to how quickly you burn your calories). If the thyroid enlarges, it can squeeze these important structures and cause problems with breathing or swallowing. One of the most common reasons for conducting a thyroid surgery is the presence of nodules or tumors on the thyroid gland. Most nodules are benign, but some can be cancerous or precancerous. However, benign nodules can also cause problems if they grow large enough to obstruct the throat or if they stimulate the thyroid or overproduce hormones (a condition called hyperthyroidism). Early and accurate diagnosis of thyroid disorders is a difficult task as in most cases the symptoms develop slowly (often over several years). General surgery medical billing and coding is quite complex, as there are several rules related to reporting the procedure accurately. General surgeons or ENT surgeons performing thyroid surgery should correctly document the procedures performed in the patients’ medical records. Medical coding outsourcing is a practical solution for physicians to simplify their documentation process.

Thyroid Surgery

Here are some frequently asked questions and answers about thyroid surgery –

Q: Why is thyroid surgery performed?

A: One of the most common reasons for thyroid surgery is the presence of abnormal growths or nodules (lumps) on the thyroid gland. In most cases, the nodules range in size from several millimeters to centimeters and could be cancerous. Surgery may be recommended for conditions like Goiter (Noncancerous enlargement of the thyroid) and Hyperthyroidism (Overactive thyroid). However, not every patient with thyroid nodules requires surgery. The main decision whether to conduct a surgery or not is taken after careful consideration of the patient’s medical history and the results of the tests done to evaluate the nodules and the functioning of the thyroid gland.

Q: What are the different types of thyroid surgery?

A: There are three different types of thyroid surgery namely – Lobectomy, Subtotal thyroidectomy and Total thyroidectomy.

  • Thyroid lobectomy – one half of the thyroid is removed.
  • Subtotal thyroidectomy – the thyroid gland is removed but a small amount of thyroid tissue is left behind (which preserves some thyroid function).
  • Total thyroidectomy – the entire thyroid gland is removed.

Q: What are the potential risks or complications involved?

A: Generally, thyroidectomy is a safe procedure. However, as with any other procedure, thyroid surgery has its own set of complications –

  • Bleeding
  • Infection
  • Airway obstruction caused by bleeding
  • Permanent hoarse or weak voice due to nerve damage
  • Recurrent laryngeal nerve injury
  • Low blood calcium

Q: Who performs the procedure?

A: In most cases, Thyroidectomy is performed by physicians specialized in otolaryngology, head and neck surgery.

Q: How long will a patient need to stay in the hospital for thyroid surgery?

A: Patients will be admitted to the hospital on the day of the surgery. In most cases, they are able to go home the same day after about 4-8 hours in the recovery room, depending on the extent of incision and timing of the surgery.

Q: What type of anesthesia is given to the patient as part of the surgery?

A: Patients are given either general anesthesia or local anesthesia at the time of the surgery. With both techniques, the surgeon will perform a nerve block so that the neck area is numbed.

Q: How are thyroid problems diagnosed?

A: Thyroid problems don’t develop rapidly. In some cases, the patient’s symptoms may be quite hard to distinguish or may be similar to other disorders. Before performing a surgery, a number of diagnosis and screening tests are conducted to determine the nature and type of thyroid disease. Laboratory analysis of blood determines the amount of active thyroid hormones circulating in the body. A TSH (thyroid stimulating hormone) test is one of the most common blood tests that helps check the thyroid hormones in the blood stream. Sonograms and CT scans may also be conducted to determine the size of the thyroid gland and location of abnormalities. In addition, a needle biopsy of the abnormality or aspiration of fluid from the thyroid gland may also be performed to determine the diagnosis. If the diagnosis is hyperthyroidism, patients may be asked to consume anti-thyroid medicine before the surgery.

Endocrinologists who provide specialized treatment are reimbursed for the services provided to the patients. Correct medical codes must be used to document the diagnosis, screening and other procedures performed. Medical billing and coding services offered by reputable companies can help physicians use the correct codes for their medical billing process.

Q: What are the medical codes used for documenting thyroid surgery?

A: The following ICD-10 codes and CPT codes are relevant with regard to thyroid surgery –

ICD – 10 Codes

  • E89.0 – Postprocedural hypothyroidism

CPT Codes

  • 60500 – Parathyroidectomy or exploration of parathyroid(s)
  • 60502 – Parathyroidectomy or exploration of parathyroid(s); re-exploration
  • 60505 – Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach
  • 60212 – Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
  • 60225 – Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
  • 60240 – Thyroidectomy, total or complete
  • 60252 – Thyroidectomy, total or subtotal for malignancy; with limited neck dissection
  • 60254 – Thyroidectomy, total or subtotal for malignancy; with radical neck dissection
  • 60260 – Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid
  • 60270 – Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach
  • 60271 – Thyroidectomy, including substernal thyroid; cervical approach

Q: How are patients evaluated prior to the surgery?

A: All patients undergoing thyroid surgery will be evaluated pre-operatively by conducting a thorough medical history review and detailed physical exam including cardiopulmonary (heart and lungs) evaluation. An electrocardiogram and a chest x-ray are often recommended for patients above 45 years of age or who are symptomatic from heart disease. In addition, blood tests may also be done to determine if a bleeding disorder is present.

Q: What patient preparations are required for the procedure?

A: Prior to your operation (at least one week before the procedure), patients will be seen by the anesthesiologist for a preoperative check. Patients will be asked questions about all the medications they are consuming and instructions will be given whether to stop or continue these medications prior to the procedure. Some of the most important preparation tips include –

  • Do not eat or drink anything after midnight on the night before surgery. However, patients can consume routine medicines for heart disease, blood pressure, or asthma on the morning of the surgery with a small sip of water.
  • Stop taking aspirin and other blood-thinning products (such as Coumadin, ibuprofen and Plavix) at least 7-10 days before surgery, unless otherwise directed by the physician.

Q: Will patients experience pain after the operation?

A: Patients will experience some pain soon after the surgery, but this can be effectively treated with small doses of pain medications. However, patients may experience conditions such as sore throat, difficulty swallowing, or a hoarse voice, all of which will subside quickly.

Ensure Reimbursement for Significantly Complex Procedures with Proper Use of Modifier 22

Ensure Reimbursement for Significantly Complex Procedures with Proper Use of Modifier 22

General surgery medical billing and coding is quite complex. When a surgeon performs an operation, it may entail more than what was planned, in which case modifier 22 increased procedural services may be applicable. Knowing how to code correctly for the surgical procedure is crucial to optimize reimbursement. Experienced coders in medical billing and coding companies accomplish this by scrutinizing the physician’s documentation.

When Modifier 22 is Relevant

The National Correct Coding Initiative states: “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported.

From this it is clear that the surgeon should accurately document the unusual circumstances of the procedure within the operative report. This should include a proper description of how the service provided differs from the usual service or the one that was planned. The physician should explain and identify additional diagnoses, pre­‐existing conditions, or unexpected findings or complications that led to the extra time and effort.

Every procedure code involves a probable range of complexity, length, risk, and difficulty. Modifier 22 has to be added to the procedure code if the service provided goes beyond these normal ranges and can be described as more complicated, complex, technically difficult, or needing significantly more time than usual. For instance, excessive blood loss relative to the procedure is a circumstance in which Modifier 22 can be appended. In this case, the surgeon’s documentation should explain the steps taken to control the blood loss.

Other situations that may support Modifier 22 include:

  • Extreme obesity that complicates surgery significantly
  • Presence of excessively large surgical specimen
  • Co-morbidities that cause complications during the surgery
  • Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
  • Other pathologies, tumors, or malformations (genetic, traumatic, surgical) that interfere directly with the procedure but are not billed separately
  • Services rendered that are significantly more complex than described for the CPT® code in question

Submitting Correct Claims for Unusual Surgical Procedures – Other Points to Note

It is crucial that the physician’s documentation submitted along with the claim specifies the extra time taken for the procedure – for instance, that the surgery took four hours instead of the usual two hours.

Every year, the Centers for Medicare & Medicaid Services (CMS) provides a “Work Time” Excel file that contains important information about median time values for all procedures listed in the CPT® codebook, and also the types of E/M services that may be encountered in the pre- and post-operative periods of a procedure. Column E on the time sheet – “Median Intra Service Time” – is especially important in general surgery medical billing and coding for reimbursement of modifier 22. The values in this column represent the time usually spent for surgical procedures. A typical surgical procedure may take more or less time than that given in the list, but the median time can be used to determine the approximate value of procedures billed with modifier 22.

Professional Medical Billing Services for Proper Reimbursement

The complexities associated with the use of modifier 22 underlines the importance of expert medical billing support. Failure to use modifiers properly can badly affect reimbursement. Certified medical coders in professional medical billing and coding companies are familiar with the use of all CPT modifiers and can help surgeons maximize their reimbursement.

Payers may reject or refuse additional reimbursement for modifier 22. A reliable medical billing company will also follow up on rejected claims and appeal the decision in cases where the procedure note is thorough and clearly reveals that additional compensation is justified for the unusual service provided.