Cheryl Posted Thu 07th of November, 2019 14:46:40 PM
My doctor removed a patients gastric band and port via an open procedure in which he was repairing a perforated duodenal ulcer with graham patch. Due to the fact the band had been exposed to purulent fluid and the patient had not been using the band in years, the doctor felt it best to be removed. He also performed an EGD. So far I'm looking at codes 43840, 49905, 43235 but there is no open code for the band and port removal. If I used an unlisted code it will more than likely not pay but be considered bundled into the other codes. I'm also considering possibly putting a modifier 22 on the main procedure instead of using an unlisted code for the added work of removing the band and port. What codes would be best used in this situation?
SuperCoder Answered Fri 08th of November, 2019 04:51:53 AM
CPT 43840 is for suturing of perforated duodenal ulcer, CPT 49905 is for intra-abdominal omental flap and CPT 43235 is for flexible EGD, all the procedure codes are appropriate to bill.
Modifier 22 is to append to a surgical procedure when the physician’s work required to perform the procedure is more than is typically needed. As per RVU, the primary procedure is 43840, so you can append the modifier 22 with the procedure. However, CPT 43999 (Unlisted procedure, stomach) can be used as there is no specific defined code for gastric band and portal removal. You can bill the claim in both the ways, although payer will decide the payment on the basis of provided medical document. Since, you are reluctant to bill the service with the unlisted code, it is suggested to bill it modifier 22 with related procedure.
In order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:
- Increased intensity
- Additional time
- Technical difficulty
- Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician
An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.
Hope this helps!