CPT 43280 Laparoscopic Fundoplasty is no longer reimbursable with Laparoscopic Adjustable Gastric Band placement (CPT 43770) and or Laparoscopic Gastric Sleeve (CPT 43775) per second quarter NCCI Edit. This does not mean that the procedures cannot be performed together, rather that the procedures cannot be billed together. This represents a major change for bariatric coding. This change mirrors what has already been in place for Laparoscopic Gastric Bypass (CPT 43644).
Previously, ASMBS has suggested using the CPT code 43280 (Laparoscopic Fundoplasty) as this code includes laparoscopic repair of the diaphragmatic crura in addition to the fundoplasty. ASMBS has suggested the addition of with reduced work modifier (-52) when billing repair of sliding type hiatal hernias when performed in conjunction with laparoscopic adjustable gastric bands or laparoscopic sleeve gastrectomy. The ASMBS felt this fairly represented the usual dissection of the diaphragmatic crura and their reapproximation. The reduced work modifier was appended to represent that a gastric fundoplication was not being performed as described in the CPT handbook.
The question then becomes is there alternate way to code for diaphragmatic crural repair/reapproximation in conjunction with bariatric surgery that is more appropriate? CPT does not have a specific code for Laparoscopic Diaphragmatic Crural Repair/Reapproximation. Below are some CPT codes the coder might be tempted to use instead of the CPT 43280. The codes are followed by some advice and reasoning on their use:
Possible coding options:
- 39599 unlisted, diaphragm (RVU not listed)
- 43281 – Lap paraesophageal hernia (RVU 45.68)
- 43282 – w mesh (RVU 51.36)
- 43289 – Unlisted Lap procedure esophagus
- 43332- paraesophageal hernia via laparotomy ( rvu 34.41)
- 43333 – w mesh ( rvu 37.41)
- 43334 – paraesophageal hernia via thoracotomy (RVU 37.65)
- 43335 – w mesh (40.54)
- 43336 – paraesophageal hernia via thoracoabdominal (RVU 44.49)
- 43337 – w mesh (RVU 48.7)
- 43499 – Unlisted procedure esophagus
Unlisted Procedure or Service Codes
It is recognized that there may be services or procedures performed by physicians or other qualified health care professional that are not found in the CPT code set. Therefore, a number of specific code numbers have been designated for reporting unlisted procedures. When an unlisted procedure number is used, the service or procedure should be described (see specific section guidelines). Each of these unlisted procedural code numbers (with appropriate accompanying topical entry) relates to a specific section of the book and is presented in the guidelines of that section. In some cases alternative coding and procedural nomenclature as contained in other code sets may allow appropriate reporting of a more specific code. CPT references to use an unlisted procedure code do not preclude the reporting of an appropriate code that may be found in other code sets.
For example: A service or procedure may be provided that is not listed in the CPT codebook. When reporting such a service, the appropriate “Unlisted Procedure” code may be used to indicate the service, identifying it by “Special Report” as discussed in the section below.
A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.
If the surgeon chooses to report and bill via the unlisted code. The operative report should contain an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Unfortunately, unlisted codes are notoriously difficult to receive payment on. Which makes this alternative less attractive.
The surgeon could use theModifier -22: increased procedural services – appended to the primary surgery procedure. Below are the guidelines for the use of the 22 modifier. Based on these guidelines, there are several reasons the 22 modifier is probably not appropriate for most surgeons:
- The use of the code should be infrequent (generally less than 10% of cases). Many surgeons have reported performing diaphragmatic crural reapproximation/repair in 50-100% of adjustable gastric band cases and up to 100% of sleeve gastrectomy cases. By definition this is not infrequent
- The amount of work is “more extensive than normal” Generally speaking crural reapproximation requires a few extra minutes to procedures that are coded at an RVU value that represents 90-105 minutes of OR time. If the dissection and repair leads to OR times significantly greater than this, the 22 modifier would be appropriate. At that point, if the hiatal hernia was substantial enough it might be better coded with CPT 43281
Modifier 22 is appropriate in reporting substantially increased procedural work than is typically required, such as;
- Trauma extensive enough to complicate the particular procedure and that cannot be billed with additional procedure codes
- Significant scarring requiring extra time and work
- Extra work resulting from morbid obesity or other unusual anatomic anomalies
- Increased time resulting from extra work by the physician
- Additional work and time involved in managing a patient’s co-morbid conditions throughout the procedure
- When work associated with bundled procedures is more extensive than normal.
CMS requires the following information when the claim is submitted:
- A concise statement about how the services differed from the usual
- An operative report submitted with the claim.
Correct Coding Initiative Guideline
“Routine use of the modifier 22 is inappropriate as this practice would suggest cases routinely have unusual circumstances. When an unusual or extensive service is provided, it is more appropriate to utilize the 22 modifier than to report a separate code that does not accurately describe the service provided.” Local Part B contractors may also have authoritative written guidelines for using modifier 22.
Occasionally a provider may perform two procedures that should not be reported together based on an NCCI edit. If the edit allows use of NCCI associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier. However, if the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the column one HCPCS/CPS code of the NCCI edit with modifier 22. The Carrier (A/B MAC processing practitioner service claims) may then evaluate the unusual procedural service to determine whether additional payment is justified.
- The surgeon’s documentation should be thorough. If it does not support the substantial additional work and the reason for the additional work, carriers will not automatically increase the fee.
- Documentation should be submitted with the claim because modifier 22 claims may spur an automatic manual review
- Additional work must be substantial. Many coding specialist say unless 25% more work was performed, modifier 22 should not be appended. For CMS and many other third-party payers, if the physician’s operative time is increased by 50% or more, modifier 22 should be appended. A second diagnosis code may be warranted to account for the unusual circumstances.
- Any additional fees should be charged up front to payers, which are unlikely to raise fees on their own just because modifier 22 is appended.
- When claims are submitted with modifier 22 appended to the procedure, the payer requires submission of documentation to validate any additional fee charged for the services.
- Use diagnosis codes to support the complexity and in the case of morbid obesity that requires additional work, the diagnosis for BMI (body mass index) must be reported with 278.01.
- You should also include
- Time: Time is quantifiable, making it easier for a payer to convert into additional reimbursement. For example, statements such as “50 percent more time than usual was required to take down adhesions because the patient’s obesity, making the total procedure 90 minutes instead of 30 minutes” can be very effective. Use of special equipment
- Technique: Clearly indicate when there has been a change in technique during the procedure and, more important, why there was a change in technique – for example, “Adhesions prohibited a successful laparoscopic procedure, hence its conversion to an open one. Or that the adhesions had to be taken down in order for the surgeon to accomplish his/her intended procedure.
While documentation supporting the use of modifier 22 can and should be found anywhere in the operative note. Best practice is to include a separate statement with supporting information detailing the additional time and/or complexity of the case. The Guidelines to the CPT surgery chapter have been updated to include instructions for a “Special Report” to describe the information that should be included in operative and procedural reports that will have increased (modifier 22). CPT now specifies that “pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary to provide the service.
Medicare and the American College of Surgeons have recommended that providers intending to submit a claim with modifier 22 “prepare a written statement of what made the service unusual. [Noridian] recommends placing a separate paragraph right in the operative note, preferably at the conclusion of the report, with a heading “unusual Procedure” [that] briefly describes, in one or two paragraphs, the difficult nature of the service(s) that justify why the service was unusual and the increased work that was necessary for that patient. Use simple medical explanations and terminology—it must be clear to a non-surgeon. Include the typical average circumstances vs. this patient’s circumstances. Compare normal time to complete a typical procedure and the actual time to complete the procedure (making clear why the additional time was required).” Although describe briefly, the information should be sufficiently detailed that the additional time and/or complexity is clearly demonstrated.
Modifier 22 Validation Letter
ABC Insurance 1234 Street Ave Anytown, USA 12345
RE: Increased Procedural Services
Patient: Member ID DOB: DOS:
Dear Medical Director:
Attached is a copy of the operative report and claim for the above-mentioned patient. This procedure was more technically demanding and time consuming than described by the CPT code 43775/43770, laparoscopic sleeve gastrectomy/laparoscopic gastric banding.
The surgery was more complex because: (List facts)
- The patient was morbidly obesity with a BMI of 41, creating more difficulty in accomplishing the procedure.
- The hiatal hernia had to be repaired. Unlike gastric bypass, not repairing the hiatal hernia could cause increased post-operative symptomology.
I estimate that the above makes this case approximately 40% more difficult than that described by CPT code 43775/43770. Therefore, I am asking for a 40% increase in the usual reimbursement for the Laparoscopic Sleeve Gastrectomy/Laparoscopic Gastric Banding performed.
Because of the unusual circumstances, we request review by a surgeon specializing in this procedure.
If you have any questions, do not hesitate to contact me at (xxx) xxx-xxxx
Bariatric Surgeon, MD Enclosed: Operative Report
Use of CPT 42381: Laparoscopic paraesophageal hernia repair, including fundoplasty, when performed.
The description of this code includes “ The physician reduces the herniated stomach into the abdomen and dissects the hernia sac and gastroesophageal fat pad using a combination of sharp and blunt dissection”. While significant paraesophageal hernias do occur in bariatric surgery, they represent a small minority (up to perhaps 8-10%). When true paraesophageal hernias occur, 43281 can be billed with all bariatric procedures in the current CCI edit.
For the patients with, a “dimple”, a “palpable weakness”, a positive balloon test, prophylactic repair, and any solely anterior repair, it has been the opinion of the ASMBS that these were best billed as CPT 43280. As such, can no longer be billed together with any primary bariatric procedure.
For patients who have a significant portion of the actual stomach above the diaphragm with an identifiable hernia sac that requires dissection (likely circumferential around the esophagus) this extra work can be billed as CPT 43281. However the reduced work modifier should be appended to represent that the fundoplasty was not performed.
Use of Codes 43332-7: Use of the codes for laparoscopic cruraplasty in conjunction with bariatric surgery would be inappropriate unless performed through one of these open techniques. The codes are high valued to represent the difficulty and morbidity of these open approaches. It is also inappropriate, to select an open code for a laparoscopic procedure, when a better laparoscopic code exists solely because a CCI edit prevents billing of the laparoscopic code.
Matthew Brengman, Chair, ASMBS Insurance Committee
ASMBS Insurance Committee Disclaimer:
The coding, billing and reimbursement of any medical treatment or procedure is highly subjective, and is dependent upon the interpretation of multiple variables, to include differing Medicare fiscal agent Local Coverage Determinations, and a wide variety of commercial insurance payers’ policies. American Society for Metabolic and Bariatric Surgery (ASMBS) presents the information as general information and a point of reference. ASMBS does not and cannot guarantee or warranty that the reliance upon any information presented in this guide will result in any provider’s compliance with a particular payer’s coding, billing or reimbursement requirements. This guide does not and cannot constitute professional advice or be a substitute for applicable professional advice regarding the coding, billing or reimbursement for any specific circumstance. ASMBS highly recommends that every provider consult a coding, billing or reimbursement professional regarding the submission of any specific claim for reimbursement.