2015 General Surgery Survival Guide

Transcription

1 2015 General Surgery Survival Guide Chapter 8: Gastric Procedures Gastrectomy Report for Lap Sleeve Gastrectomy When your general surgeon performs sleeve gastrectomy by lap approach, report the service with (Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy {i.e., sleeve gastrectomy]). Gastrostomy A gastrostomy is a surgical opening from the external surface of the abdominal wall into the stomach. Most commonly, surgeons will perform gastrostomy to place a feeding tube (gastrostomy tube, or "G-tube") to provide nutrition for those patients who cannot swallow. In other cases, the G- tube may provide drainage to bypass an obstruction from tumor, scarring, or ulcer. The physician may insert the tube by way of a laparotomy (an "open" or incisional approach), percutaneously (through the skin) or, as is increasingly common, using an endoscope. During an endoscopic approach properly called a percutaneous endoscopic gastrostomy (PEG) the physician passes an endoscope down from the mouth into the stomach. Using the scope's bright light to position a small incision on the abdominal wall's surgically prepped skin, the physician then inserts a hollow needle through the incision passing through the abdominal wall and into the lumen of the stomach. She next threads a thin wire through the needle and, using a snare attached to the endoscope, grasps the wire and pulls it from the stomach, through the esophagus, and up and out the mouth. Finally, after attaching a gastrostomy tube to the wire emerging from the mouth, the physician gently pulls out the wire entering the abdominal wall, drawing the attached gastrostomy tube down the esophagus and out the stomach. The tube emerges through the abdominal wall, where the physician secures it at the site of the abdominal puncture. CPT codes that describe gastrostomy and gastrostomy-related procedures include: Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective Laparoscopy, surgical; gastrostomy, without construction of gastric tube (e.g., Stamm procedure) (separate procedure) Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance Repositioning of a naso-or oro- gastric feeding tube, through the duodenum for enteric nutrition Gastrostomy, open; without construction of gastric tube (e.g., Stamm procedure) (separate procedure) neonatal, for feeding with construction of gastric tube (e.g., Janeway procedure) Closure of gastrostomy, surgical Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, and jejunostomy Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance

2 including contrast injection(s), image documentation and report Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastrojejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastrojejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report. Stick With for True PEG If your physician places a true PEG tube, you should always select This is the type of procedure you will see frequently. What to look for: The operative note for will describe an upper GI endoscopy with gastrostomy tube insertion. As the code descriptor specifies, placement of this type involves both an endoscopic and a percutaneous (through the skin) component. Surgeons will usually place the tube without performing any other abdominal procedures at the same time. You Can Report Multiple Endoscopies If the surgeon performs another endoscopic procedure (for instance, 43239, Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) during the same session as PEG tube placement (43246), you can bill for both procedures separately. Keep in mind, however, that the multiple-endoscopy rule will apply. The payer will reimburse only the higher-valued procedure at 100 percent of the fee schedule amount. For the lesser-valued procedure, you will receive the standard fee schedule amount minus the value of the "base" endoscopic procedure in this case (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure]). No Endoscope Calls for When the physician places a gastrostomy tube percutaneously without using an endoscope, you should select rather than Guidance provides a clue: During this percutaneous procedure, the surgeon punctures the abdominal wall from outside the body and inserts a device under fluoroscopic or ultrasound guidance. This allows the surgeon to pull the stomach up to the abdominal wall and then insert the tube percutaneously without using an endoscope. Include supervision and interpretation (S&I) in 49440: You cannot code separately for fluoroscopic imaging with percutaneous placement of the gastrostomy tube. Rather, will include all of the components to place the tube. Look to for Laparoscopic Placement

3 Laparoscopic gastrostomy (43653) differs from endoscopic gastrostomy, and you should be careful not to confuse the two. Most commonly, the physician will perform laparoscopic gastrostomy if he is already using the laparoscope for another procedure (such as to obtain a biopsy). Important: You should note that is a designated "separate procedure." This means that if the surgeon performs any other laparoscopic service at the same time, you can't report separately. For example, you should not report separately if the surgeon performs a laparoscopic fundoplication (Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]) at the same time. If your physician uses the laparoscope for the sole purpose of placing the gastrostomy tube, you may report separately. Usually, the only time surgeons will employ the laparoscope for placing a gastrostomy tube is when the patient cannot swallow an endoscope due to some technical reason. Select for Percutaneous Tube Replacement You should report if the surgeon replaces a PEG tube because of clogging or other factors. This code does not include imaging guidance. Watch for endoscope use: Sometimes, the physician may encounter a problem replacing the tube percutaneously (for example, if the physician is unable to move the tube). In such cases, the physician may perform a diagnostic endoscopy to determine the problem and assist in the tube removal. The physician then places the replacement tube percutaneously without using the scope. In this case, you should report the diagnostic endoscopy (43235) and the percutaneous tube replacement (43760) separately. Just be sure that the physician documents in the patient record the medical necessity for performing the endoscopy. Note, however, that if the physician does use the endoscope to place the feeding tube, you should once again revert to 43246, according to CPT instructions. In this case, you would not report either or Describes 'Open' Procedure You should report (without gastric tube), (with gastric tube), or (for feeding a neonate) when the surgeon performs gastrostomy using an open approach (via a midline incision of the upper abdomen). Open gastrostomy is relatively rare now, but may occur during another, more extensive open procedure, or as a last resort when the surgeon cannot place the tube using any other method. Warning: Like percutaneous gastrostomy (43653), open placement (43830) is a "separate procedure." Therefore, you cannot report separately if open placement takes place the same day as another procedure in the upper abdominal or stomach area. Call on for Replacement With Guidance When the physician replaces a gastrostomy tube under fluoroscopic guidance, you'll want to select This procedure includes using contrast material, as well. Code differs from because the latter describes replacement without fluoroscopic guidance. More maintenance codes: Additional codes for gastrostomy tube maintenance include for mechanical removal of obstructive material by any method and to describe radiological evaluation of an existing gastrostomy tube via a percutaneous approach. Both and include fluoroscopic guidance, when performed. Conversions Call for Special Code

4 52 Makes the Case for Bolster Replacement If your surgeon documents replacement of a "mushroom basket," report with modifier 52 (Reduced services) appended. A mushroom-shaped basket, or bolster, holds the PEG tube in place on the inside of the stomach wall. Sometimes the physician will need to replace this device, which involves using endoscopy to go back into the stomach. Because this procedure basically includes a reduced version of PEG tube placement, you are correct to describe it using Tip: Be sure that you include documentation with your claim explaining the placement's reduced nature. When your physician converts a gastrostomy tube to a gastrojejunostomy tube, you should report The gastrojejunostomy tube is a dual-lumen feeding tube. Typically, the gastric lumen is used for decompression, while the jejunal lumen administers nutrition. Like many gastrostomy procedures, includes fluoroscopic guidance, when used. You would not report any additional codes with for guidance, contrast injection(s), image documentation, and report. Access Modifier 78 for Complications You should append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) when the surgeon must return the patient to the operating room within the global period for reasons related to the original surgery (such as postoperative complications). For example, the surgeon places a gastrostomy tube (49440), but eight days later, the tube leaks and the physician returns the patient to the operating room to change the tube. Coding fix: The surgeon must append modifier 78 to for the second procedure because carries a 10- day global period. Don't Overlook V Codes Don't be fooled by the misconception that you can't use a V code as a primary diagnosis. In fact, there are a number of circumstances when a V code is not only appropriate but also necessary as a primary diagnosis. For example, when the physician attends to an artificial opening, such as a gastrostomy, you may list a V code as primary. Eligible codes include V55.0-V55.9 (specifically V55.1, Attention to artificial openings; gastrostomy) and V58.81-V58.82 (Other specified procedures and aftercare; fitting and adjustment of vascular catheter). Caution: You should not report V44.0-V44.9 (Artificial opening status ) as primary diagnoses. These diagnoses only indicate that the patient has undergone an ostomy procedure, not that the surgeon has performed any particular service. You should report these codes as secondary only. 'Miller-Abbott' Tubes Require a Unique Code If you run across documentation referring to a "Miller-Abbott" or long gastrointestinal tube, don't make the mistake of coding it as a PEG. Surgeons generally use the Miller-Abbott tube for drainage rather than enteral feeding. Miller-Abbott tubes are longer than PEG tubes, and surgeons often use them when the patient has an intestinal obstruction. When the surgeon places a Miller-Abbott tube, you should report (Introduction of long gastrointestinal tube [e.g., Miller-Abbott] [separate procedure]).

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