Ob-gyn coders often include lysis of adhesions in the primary surgery, but you can get paid separately for the procedure if the adhesions are extensive.
Pelvic adhesions are bands of fibrous scar tissue that can form in the abdomen and pelvis after surgery or due to infection. Because adhesions connect organs and tissue that normally are separated, they can lead to a variety of complications, including pelvic pain, infertility and bowel obstruction. Adhesions commonly form on the ovaries, pelvic side walls and fallopian tubes.
Although ob-gyns generally deal with lysis of adhesions in only four sites, CPT provides six codes for the associated procedures:
- 44005 – Enterolysis (freeing of intestinal adhesion) (separate procedure)
- 44200 – Laparoscopy, surgical; enterolysis (freeing of intestinal adhesion) (separate procedure)
- 56441 – Lysis of labial adhesions
- 58559 – Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
- 58660 – Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
- 58740 – Lysis of adhesions (salpingolysis, ovariolysis).
Generally, you should separately report adhesiolysis in only two situations when performed with another procedure(s):
1. when lysis of adhesions is extensive
2. when the adhesions are in a different anatomic site from the main procedure(s).
If the lysis of adhesions is extensive and bundled into the primary procedure by the National Correct Coding Initiative or some other bundling software, you should add modifier -22 (Unusual procedural services) to the primary procedure code. Otherwise, you should report extensive adhesiolysis separately.
You should use modifier -22 only rarely, says Jean Ryan-Niemackl, LPN, CPC, content analyst for QuadraMed health information management division in Fargo, N.D. Every surgeon has cases that are harder than average and ones that are easier” and just because a case is more extensive or time-consuming than another is not reason to use modifier -22.”
To report modifier -22 you should have supporting documentation that details the physician’s extensive time and work effort. “Modifier -22 will most certainly initiate a request for information from your carriers so it is important that you have good substantiation in the operative report ” Ryan-Niemackl says.
The following tips will help you pin down when you should report lysis of adhesions separately.
Separate Codeable Adhesiolysis From Noncodeable
When determining whether you should code adhesiolysis in addition to the primary procedure you first have to examine the ob-gyn’s documentation. Carriers usually don’t reimburse separately for removing soft filmy adhesions by blunt dissection when the physician performs the lysis with other procedures. His or her documentation must describe the significant work associated with the removal (using sharp dissection and sometimes laser) of adhesions that are dense very adherent and have a blood supply.
For example the ob-gyn documents that while performing abdominal surgery he lysed both intestinal and pelvic adhesions and the adhesions were dense anatomy-distorting and took a very long time to lyse. In this case you may be able to report both 44005 and 58740 in addition to the code for the primary surgery because the adhesions were extensive and required significant time to lyse.
Differentiate Between Bowel and Pelvic Adhesions
Establishing where the surgeon lysed the adhesions is the next major step to determine which code to select. If the ob-gyn performed adhesiolysis of the bowel you would report 44005 or 44200 depending on the approach if possible says Carol Pohlig BSN RN CPC senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. If the physician lysed pelvic adhesions you should submit 58660 or 58740 depending on the adhesions’ exact location if appropriate she adds.
For instance the surgeon notes that during a laparotomy he encounters dense adhesions involving the bowel and omentum which require two hours of adhesiolysis and enterolysis to adequately expose the uterus and pelvis so he could perform a hysterectomy. Based on this information you would report 44005 in addition to 58150 (Total abdominal hysterectomy [corpus and cervix] with or without removal of tube[s] with or without removal of ovary[s]).
But the National Correct Coding Initiative (NCCI) bundles 44005 into 58150 with a “0” modifier indicator meaning no modifier can override the edit Pohlig says. Therefore you should report the extra work involved with the extensive adhesiolysis by appending modifier -22 to 58150.
Determine When Adhesiolysis Changes Approach
Occasionally an ob-gyn attempts a procedure laparoscopically but because of extensive adhesions he or she must change to an open approach to complete the surgery. In this case the laparoscopy is bundled into the open procedure under Medicare rules and the rules of many payers that follow Medicare so you can’t report it separately. The only option is to report the primary surgery appended with modifier -22.
Let’s say the ob-gyn surgeon inserts the laparoscope intending to perform a transvaginal sling. Upon inserting the scope he finds massive adhesions on the left side of the bowel adhering not only the bowel to the pelvic sidewall but also the left tube and ovary. The right side is even worse. After attempting to remove the adhesions for an hour with little success the physician decides to convert to a laparotomy to complete the procedure.
Because the surgeon took significant additional time attempting to perform the procedure laparoscopically you should report 57288-22 (Sling operation for stress incontinence [e.g. fascia or synthetic]). “Quantifying the additional time and effort in the documentation is crucial for reimbursement success ” Pohlig says. In addition to reporting the time in the procedure note include a cover letter that compares the additional time and effort to the average time and effort the procedure usually takes to perform she suggests.
Estimate Dollar Amount When Using Modifier -22
“If you are not adding a dollar amount before submitting to your carriers you are doing a disservice to yourselves ” Ryan-Niemackl says. When submitting a claim that includes modifier -22 you should include an estimate of what you expect to be paid for the extra work involved in the procedure. “Otherwise you are leaving the decision up to the carriers and potentially the reimbursement will be based on their standard allowable ” she says. Including a dollar amount doesn’t mean the payer will reimburse based on your charge but as with all submissions you don’t want to leave the decision entirely up to the carrier.”