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D Posted 6 Year(s) ago

Hi- can someone please help. I have physician billing for whipple procedures and am wondering what CPT codes physician may bill for, or are certain procedures included. For example the following codes were billed for this patient:
"48153; 15734-51; 35221; 43832; 47100; 38747-59; 44015; 76998-26"
Here are the procedures which were performed.
1.Pylorus-preserving pancreaticoduodenectomy (Whipple procedure)
2.Myofascial abdominal wall flap (falciform pedicle flap).
3. Major vascular reconstruction (superior mesenteric vein).
4. Cholecystectomy.
5. Total omentectomy.
6. Intra-abdominal lymphadenectomy.
7. Gastrostomy tube with intestinal tube formation.
8. Jejunostomy tube placement.
9. Intraoperative ultrasound of the liver (images stored in patient's chart).
10. Excision of right hepatic lobe mass (wedge resection of the liver)

In regards to the lymphadenectomy- the MD states "Along with the tumor,peripancreatic, periduodenal, superior mesenteric vein and superior mesenteric artery lymph nodes were all dissected en bloc with the tumor and this constituted the intra-abdominal lymphadenectomy."
In regards to the wall flap the MD states "A myofacial abdominal wall flap was raised off the anterior abdominal wall,taking care to preserve the blood supply as it emanated from the liver."

Thanks so much

SuperCoder Posted 6 Year(s) ago

1.Pylorus-preserving pancreaticoduodenectomy (Whipple procedure)-48153
2.Myofascial abdominal wall flap (falciform pedicle flap)-15734
3. Major vascular reconstruction (superior mesenteric vein)-35221
4. Cholecystectomy-47600 Not reportable
5. Total omentectomy.49255 Sep Px Not reportable
6. Intra-abdominal lymphadenectomy.-38747, No 59 because of add on code.
7. Gastrostomy tube with intestinal tube formation.-43832
8. Jejunostomy tube placement.-44015 (Add on Code)
9. Intraoperative ultrasound of the liver (images stored in patient's chart)-76998-26
10. Excision of right hepatic lobe mass (wedge resection of the liver)-47100

Knowing if the surgeon joined the jejunum and pancreatic duct cuts your code selection in half

Reporting a Whipple procedure can be a cinch, as long as you recognize the various names by which surgeons may call this surgery, as well as the confusion of terminology that describes the options that can occur during the procedure. Here are some tips to help you on your way.

Know the Procedure by Name

Be aware that your surgeon may not always refer to a Whipple as a Whipple. Other common names for the procedure include pancreaticoduodenectomy, pancreat-ectomy with duodenectomy, pylorus-sparing pancreaticoduodenectomy or Traverso-Longmire procedure, and Kausch or Kausch-Whipple procedure.

Regardless of what you call it, you will report a Whipple using one of four codes, depending on the procedure’s specifics:

• 48150 -- Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy

• 48152 -- … without pancreatojejunostomy

• 48153 -- Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy

• 48154 -- … without pancreatojejunostomy.

All Whipple procedures involve removing the head of the pancreas (pancreat-ectomy) and at least a portion of the duodenum (duodenectomy), and joining of the common bile duct to the intestine (choledochoenterostomy), says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.

As indicated by the 48150-48154 descriptors, a Whipple procedure may also include removing a portion of the stomach (partial gastrectomy), and creating a link between the stomach and the jejunum (gastrojejunostomy); the duodenum and the jejunum (duodenojejunostomy); or the jejunum and a pancreatic duct, cyst or fistula (pancreatojejunostomy).

Look for Extent of Duodenectomy, Gastrectomy

To make your code selection easier, scan the op note to determine whether the surgeon removed all, or only a portion, of the duodenum (the first or proximal portion of the small intestine).

For a total duodenectomy, you will look to either 48150 or 48152. For a partial duodenectomy, either 48153 or 48154 is appropriate. In either case, whether the surgeon also performs a pancreatojejunostomy will determine the final code selection, Bucknam says.

Tip: If the surgeon performs a partial gastrectomy and gastrojejunostomy, the procedure will have included a total duodenectomy. If the surgeon performs duodeno-jejunostomy, however, this is evidence that he has spared the pylorus (and thus normal gastric emptying), and only a partial duodenectomy has occurred.

Pancreatojejunostomy Seals the Deal

If the surgeon performs jejunostomy during the same operative session as pancreatectomy, you should report 48150 or 48153, depending on whether the surgeon also performed a partial or complete duodenectomy.

Include Cholecystectomy

A Whipple procedure usually (but not always) includes removal of the gallbladder and ligature of the cystic duct as described in most standard surgical texts, says M. Trayser Dunaway, MD, a surgeon, coding educator and healthcare consultant in Camden, S.C.

The national Correct Coding Initiative bundles open cholecystectomy (47600) to all Whipple procedures, and as a result you should not report 47600 separately with 48150-48154.

D Posted 6 Year(s) ago

Thank you, I just wanted to clarify that in this instance it would be correct to code for lymphadenectomy- the MD states "Along with the tumor,peripancreatic, periduodenal, superior mesenteric vein and superior mesenteric artery lymph nodes were all dissected en bloc with the tumor and this constituted the intra-abdominal lymphadenectomy."

SuperCoder Posted 6 Year(s) ago

Yes, I would go with it to code 38747 separately.

D Posted 6 Year(s) ago

Hi- I am a little confused re modifier 59 for 38747- earlier post stated no modifier 59 due to add on code, however CCI edits column 1 for CPT code "48153" indicates "38747" in column 2 leading me to think modifier 59 does need to be applied.

SuperCoder Posted 6 Year(s) ago

Hi, Donna, This is Jen Godreau, CPC, CPMA, CPEDC, the director of SuperCoder. I was asked to weigh in on the answer based on the modifier discrepancy.

You are correct that you should use modifier 59 on '38747' per CCI's edit on '48153' and '38747'. The previous respondent followed the same advice that many coders incorrectly believe that modifier 59 is never used on an add-on code. They are confusing an add-on code's definition of being modifier 51 exempt with being modifier 59 exempt.

The only information I found confirming this confusion was on an AAPC forum

Beginning in 2010 CCI version 16.0 began bundling add on code 38747 with certain procedures such as 44150, etc. No one in our office has seen where we have had to use -59 modifier on an add on code before. We thought maybe it was one of the many mistakes in this first version. But when the CCI version 16.1 came out for the second quarter it still shows being bundled. We have researched this and keep coming up short of a clear answer. One time the claim is paid and the next it is denied. Has anyone else come across this issue and may have an explanation as to why this is now bundled?

I posted on this same issue on 5/26 and no one has answered mine, either! I did "search" using 38747 b/4 I posted but I didn't get any results - then today when I was trying to find my post to see if there were any answers, it turned up both mine and yours! I originally planned to go to the ntl. conference this year and was going to try to get some info there, but when they had to change the site I couldn't go after all, so tried posting. No luck after this long tells me we aren't missing anything - there really ISN'T a rational explanation for this! What a pain - I've gotten them to change the NCCI b/4, but it takes a long time and this seems so obviously erroneous!

Posted by D, 6 Year(s). There are 6 posts. The latest reply is from SuperCoder.

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