How to Convert Diagnostic Procedures to Open CPT Coding

Whenever possible, a physician prefers to use the most minimally invasive procedure available to perform a procedure or surgery.The procedures are usually done on an outpatient basis, thus exposing the patient to less potential for infection. Healing time is quicker, and the patient can usually resume normal activities quickly. For example a diagnostic laparoscopy is a procedure that allows a physician to look directly at the inside of a patient's abdomen or pelvis, including the fallopian tubes, ovaries, uterus, small bowel, large bowel, appendix, liver and gallbladder. A very small incision is made in the stomach. Diagnostic laparoscopy is ICD (International Classification of Diseases) coded as 54.21. A code for the laparoscopy is used when it is the only procedure performed (e.g., diagnostic laparoscopy). However, sometimes the diagnostic exam develops into an open surgery. The question after completion of the surgery is how to bill for it.

Things You'll Need

• Current CPT coding guide (Current Procedural Terminology)
• Current ICD-9 guide

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Instructions

• 1

  Code the more invasive procedure only for Medicare patients. If a laproscopic procedure began, CPT code 54.21 but was not completed as the surgeon decided that an open procedure of gallbladder removal CPT code 47605 was medically needed, code the open procedure (47605 ) only. The reference material for Medicare coding is the Correct Coding Initiative, copyright held by the CMS (Centers for Medicare and Medicaid).

  ICD coding and CPT coding determine the fee for the surgeon. In fact, there are certain ICD codes and CPT codes that are mutually exclusive and should never be billed together. For instance, an ICD code relating to a prostate is mutually exclusive to a CPT code for knee endoscopy. They are not related.

• 2

  Using a modifier is incorrect if the patient is on Medicare. Modifiers are suffixes to CPT codes that add further definition to the code. Things become confusing when billing for a laproscopic procedure that turns into an open procedure because there are modifiers that seem to apply to this very situation. While most insurance companies follow Medicare billing procedures, some do not.Some billers choose to follow the American Medical Association's Current Procedural Terminology manual. Though the CCI and the CPT manuals are very similar. The AMA does differ from CCI coding as it allows for more generous use of modifiers that can lead to a higher physician payment.

• 3

  For insurers who follow CPT guidelines, adding modifier -53 to CPT code 54.21 is correct. Modifier 53 means discontinued procedure.

  Other coders might add modifier 22 to the open procedure 47605 which decodes to unusual procedure. This is only correct on occasions where there was significant time and effort involved in the discontinuing a diagnostic procedure to perform an open surgery.

  For a Medicare patient the procedure should be coded as 47605 .

  For a private insurance company the proper coding is usually 54.21-53 followed by 47605.

  In both cases, the gallbladder surgery was an example, the correct code for the actual open procedure that the surgeon performed has to be the one coded.