In some situations, a general surgeon may receive additional reimbursement for a laparoscopic cholecystectomy (lap chole). For example:
If significant additional work or time is required to lyse adhesions, repair a complication or convert the procedure from laparoscopic to open, modifier -22 (unusual procedural services) can be appended to the appropriate code and additional payment claimed; or
If the surgeon performs a cholangiogram with no radiologist present and provides the supervision and interpretation (S&I).
Additionally, by carefully reviewing the surgeons procedure notes, coders may uncover additional payment opportunities. For example, cholangiograms are frequently performed in conjunction with cholecystectomies (both laparoscopic and open), but occasionally the former procedure is not listed at the top of the operative report.
To optimize reimbursement in these situations, surgeons and their coders must ensure that documentation is both accurate and complete. Coders must also be aware of several coding guidelines and bundling edits that may apply.
A lap chole involves removal of the gallbladder using a laparoscope, and may be performed with or without cholangiography. The surgeon may also explore the common bile duct for gallstones at the same time. CPT 2001 includes the following lap chole procedures:
47562 laparoscopy, surgical; cholecystectomy;
47563 ... with cholangiography; and
47564 ... with exploration of common duct.
These codes which correspond to similar open procedures that follow in the CPT manual are arranged sequentially (i.e., 47563 includes 47562 plus cholangiography, and 47564 includes 47563 plus exploration of common duct). This is reflected in the relative value units assigned to each procedure: 47562, 18.17; 47563 19.59; 47564, 23.59. Therefore, these codes should never be billed together.
Tip 1: Read the Entire Operative Report
Cholangiography is often (but not always) performed when a gallbladder is removed to help the surgeon better determine the patients anatomy and to check for gallstones in the common bile duct, says Tray Dunaway, MD, FACS, a general surgeon and evaluation and management coding author in Camden, S.C. Some surgeons routinely include cholangiography (many surgeons have been trained to do so), whereas others may perform the service only for specific indications, such as an elevated liver function study, an ultrasound that shows an enlarged common bile duct or because the patient has a history of gallstone pancreatitis.
Because cholangiography is routinely performed in conjunction with a lap chole, some surgeons forget to mention cholangiography at the top of the operative report, says Elaine Elliott, CPC, an independent general surgery coding specialist in Stuart, Fla. If you read the top of the operative [...]