"General surgeons typically do not perform many endoscopic explorations of the small intestine and may be unfamiliar with the unique coding involved in billing such procedures.
Many coders dont know what to look for in the CPT manual because these codes arent found in the typical spots general surgery coders look, says Kathy Mueller, RN, CPC, CCS-P, an independent general surgery coding
and reimbursement specialist in Lenzburg, Ill.
Unlike colonoscopies, which surgeons perform routinely, these procedures arent performed often, and the codes are tucked away in a section of the CPT manual used more by gastroenterologists or urologists than general surgeons, Mueller says. Its important to be able to identify these codes correctly, based on the information in the op note, she says, because small bowel endoscopies are well-paid procedures.
In the following case study, the surgeon first performs an endoscopy of a previously created ileal conduit to rule out carcinoma. The scope doesnt find anything, so a day later an exploratory laparotomy with biopsy of an abdominal mass adjacent to, but not inside, the ileal conduit is performed. When the pathology report identifies the mass as cancerous, the surgeon excises it.
Operative Report No. 1
Preop diagnosis: Intra-abdominal mass, rule out tumor involving the ileal conduit
Postop Diagnosis: Same
Operations: Panendoscopy of the ileal conduit Loop-o-gram
OP finding/indications for surgery:
Patient has intra-abdominal mass on CT scan. Patient has known carcinoma of the bladder and previously underwent radical cystectomy with ileal conduit urinary diversion in 1994. A surveillance CT scan shows intra-abdominal mass. Repeat CT scan shows a large intra-abdominal mass, with possible tumor involving the ileal conduit. On panendoscopy, no tumor was identified within the ileal conduit. A loop-o-gram shows no filling defects inside the conduit itself, although there appears to be some extrinsic pressure, which would indicate that this tumor is an intra-abdominal mass, but not invading the conduit and incidental reflux of contrast into the right ureter.
Technique of operation:
A #22 french rigid cystoscope was introduced into the conduit. Panendoscopy was then performed. There is no definite tumor identified within the lumen of the ileal conduit. I was able to identify the ureteral orifice and I tried to cannulate it with a glide wire, but I could not advance it beyond the meatus. There was no tumor identified in the meatus or inside the conduit itself. Next, the cystoscope was removed. A #16 french foley catheter was then placed within the conduit, and the balloon was inflated to 5 cc. Fifty cc of contrast material was injected through the catheter and filled the loop. X-rays were taken and showed reflux of the contrast in the right ureter. No effusion into the left ureter. [...]