Colon and Rectal Surgery · Proctosigmoidectomy with coloanal anastomosis, TATA Procedure What is...
Transcript of Colon and Rectal Surgery · Proctosigmoidectomy with coloanal anastomosis, TATA Procedure What is...
Colon and Rectal Surgery
Lyndia Carroll-Smith, CPC, CGSC
“
“As a Colon and Rectal Physician, I
worked my way up from the bottom”
What is Colon and Rectal Surgery
• Colon and rectal surgery is the sub-specialty of General
surgery where the treatment is primarily focused on the
disorders of the colon, rectum, and anus
• Surgeons in this field are often referred to as Proctologist.
(procto is a combining form meaning anus or rectum)
Colon and Rectal Disorders
Colon and rectal surgeons have expertise in treating :
• Cancer of small bowel, intestine – C17 (4th)
• Cancer of colon, large bowel – C18 (4th)
• Cancer of rectum – C20
• Cancer of anus and anal canal – C21 (4th)
Colon and Rectal Disorders Cont…
• Polyps
Non-adenomatous or Hyperplastic
Colon - K53.5
Anus – K62.0
Rectal – K62. 1
Adenomatous – D12(4th)
Small Intestine – D13.3 – D13.3(5th)
Colon and Rectal Disorders Cont…
• Inflammatory Bowel Disease (IBS), such as Crohn’s and
Ulcerative Colitis (K50 – K52)
• Diverticular disease K57(4th and 5th digit)
• Hemorrhoids – K64(4th)
• Fistula – K61(4th) and fissure – K60(4th)
• Motility issues such as constipation, IBS (K58 – K59.9)
Colon and Rectal Procedures
Colon and Rectal Surgeons treat the patient through procedures performed by various techniques:
• Open surgery
• Laparoscopic surgery
• Hand-Assisted
• Single Port
• Robotic procedure
• Transanal Endoscopic Microsurgery
Open Procedures
• Resections
• Enterectomy (44120 – 44128)
• Colectomy (44140 – 44160)
• Proctectomy (45110 – 45123)
• Repairs (44602- 44680)
• Rectal Repairs (45500- 45825)
• Ileostomy / Colostomy (44310 – 44346)
Surgical Approaches for Open
Procedures1. Kocher’s Incision
2. Midline
3. Gridion Muscle Splitting
4. Battle Incision
5. Lanz Incision
6. Paramedian
7. Transverse
8. Rutherford Morrison
9. Pfannenstiel
Surgical Approaches
The most common surgical approaches for open
abdominal colorectal surgery is:
• Midline
• Transverse
• Pfannenstiel – sometimes referred to as low
transverse incision
Surgical Approaches
• Hand Assisted Laparoscopic – A small incision,
2-3 inches, is used for the hand, and instruments
are use to perform the surgery
• Single Port Site – All instruments are placed
through a small incision usually 2 inches in length
Robotic Surgery
Robotic surgery, or Robotic-assisted surgery is the minimally invasive tool that provides a three dimensional image, uses wristed instruments, and has a computer interface.
• Robotic-assisted colorectal procedures:
• Colon Resection Surgery
• Rectal Resection Surgery
• Rectopexy
Robotic Surgery
S2900 - Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)
• Most payers do not allow additional reimbursement for Robotic-assisted surgery
• Some payers will reject and deny claim using S2900
• Use of modifier 22 is not appropriate
Transanal Endoscopic Microsurgery
TEM or TEMS Procedure
Report using 0184T
TEM is a minimally invasive procedure performed through the rectum with specially designed microsurgical instruments which can remove lesions high inside the rectum. These were previously accessible only with major abdominal surgery.
Transanal Endoscopic Microsurgery
Example:
Following administration of general anesthesia, the
patient is placed in a lithotomy position. Dilation of
the rectum is achieved and maintained with
constant-flow carbon dioxide insufflation. The
proctoscope is inserted and a full-thickness
excision of the tumor is achieved.
TEMS Continued
???????????
45171- Excision of rectal tumor, transanal
approach; not including muscularis propria (ie,
partial thickness), or
45172 – when muscularis propria is excised
**This coding is not accurate and can result in a
post pay recoupment**
Transanal Procedure
Transanal Transabdominal Radical Proctosigmoidectomy with coloanal anastomosis,
TATA Procedure
What is it:
• Endoscopic surgical procedure for the removal of rectal tumors.
Similar to the TEMS procedure, however TATA allows for advanced
visibility, and allows the surgeon to know preoperatively whether the
sphincter can be preserved.
• Abdominal portion is usually laparoscopic
• Follows Chemoradiation
There is no CPT Code
for the procedure
TATA procedure
The abdominal approach begins by using the Da Vinci Si robot. Trocars are placed. After completion of pneumoperitoneum. The patient is placed in the Trendelenburg position. Medial to lateral approach is performed for left colon dissection. The procedure begins with retroperitoneal dissection using the inferior mesenteric vein with a tent to reach the parietocolic gutter. Ligation of the vein and inferior mesenteric artery at its origin. Then is made the release of the colon of the parietocolic gutter and the complete take down of the splenic flexure. It is certified that the colon is with good mobility for a low colorectal anastomosis and then is performed the pelvic approach with robotic mesorectal excision. Transanal approach begins with the use of Transanal Endoscopic Operation. Anal digital expansion is performed for TEO system introduction, pneumoreto is held. Exposition of the dentate line and tumor identification.
TATA procedureDistal margin of resection is defined, making purse string suture to close the rectal stump using 3.0 Vicryl®. After a circumferential demarcation of the rectum with the use of monopolar electrocautery, dissection proceeds to the avascular posterior portion to the pre-sacral fascia, completing the circumferential dissection by mesorectal approach until the peritoneal reflection and reaching the robotic dissection.
Surgical specimen is removed transanally. After extraction of the specimen and colon section was performed purse string suture and a 33 mm circular stapler head is attached and returned the colon into the abdominal cavity. A robotic pouch suture of the rectal stump was performed to proceed the anastomosis with 33 mm stapler. The TEO was held for revision of the anastomosis.
TATA Procedure
No Code???
Open Procedure:
• 44147 Colectomy, partial; abdominal and transanal approach
• 45112 Proctectomy, combined abdominoperineal, pull-through procedure (e.g., colo-anal anastomosis)
• 45119 Proctectomy, combined abdominoperineal pull-through procedure (e.g., colo-anal anastomosis), with creation of colonic reservoir (e.g., J-pouch), with diverting enterostomy when performed
• 45110 Proctectomy; complete, combined abdominoperineal approach, with colostomy
TATA Procedure
Laparoscopic Procedure:
• 44395 Laparoscopy, surgical; proctectomy, complete,
combined abdominoperineal, with colostomy
• 44397 Laparoscopy, surgical; proctectomy, combined
abdominoperineal pull-through procedure (e.g., colo-anal
anastomosis), with creation of colonic reservoir (e.g., J-
pouch), with diverting enterostomy, when performed
TATA Procedure
• Code for the abdominal portion of the procedure using the
appropriate CPT code for approach and resection
• Code 0184T for the TEMS portion of the procedure.
• Provide documentation for reimbursement.
• A 52 modifier may be necessary for abdominal portion of
procedure.
44160, 44140, or 44120
Deciding which to choose between CPT codes
44160, 44140, and 44120 basically boils down to:
• Anastomosis
• Laterality (Right or Left Colon)
44160, 44140, or 44120
44160 – Colectomy, partial, with removal of terminal ileum
with ileocolostomy
Right Hemicolectomy
Cecetomy
Right Colectomy
44205 – Laparoscopic
Anastomosis is between the terminal ileum and the colon.
44160, 44140, or 44120
44140 - Colectomy, partial; with anastomosis
44204 – Laparoscopic
Anastomosis is between the remaining ends of the colon
44160, 44140, or 44120
44120 – Enterectomy, resection of small intestine; single resection and anastomosis.
44202- Laparoscopic
Anastomosis is performed between the remaining small bowel ends
44160, 44140, or 44120
To avoid confusion when deciding which code to assign,
remember:
The documentation must mention that the terminal ileum or
part of the ileum was removed and that the remain ileum
was anastomosed to the colon to bill 44160. Otherwise, for
a colon resection 44140 will be the most appropriate.
44160, 44140, or 44120Example:
The patient was brought to the OR. After being prepped and draped in a sterile fashion, a midline incision was made. Decision was made to proceed with a right hemicolectomy including the small bowel. The left colon was mobilized. The left ureter was identified. The mid descending colon was transected with a stapler. The rectum was mobilized all the way down below the peritoneal reflection. This was then transected, and that specimen was removed. The right colon was identified and was mobilized. A side-to-side, functional end-to-end anastomosis was performed. The small bowel withright colon was removed. The splenic flexure was then taken down using electrocautery, taking down the splenic flexure completely, mobilizing the colon all the way to the level of the mid transverse colon. A purse string suture was placed on the cut end of the colon, and an end-to-end anastomosis was performed using a 29 mm stapler. Insufflation revealed no evidence of leaking..
44140, 44160, or 44120
Because the report states that “The small bowel with right colon
was removed”, CPT code 44160 would be appropriate for
reporting this portion of the procedure.
Correct coding for total procedure:
44145
44160 – 59
Using Modifier 62When billing APR’s, modifier 62 is acceptable when the
physicians have dictated operative reports indicating their
separate performances in the surgical case.
“If the two surgeons (each a different specialty) are required
to perform a specific procedure, each surgeon bills for the
procedure with a modifier 62.” (CMS, 2019)
Co-surgery can also refers to surgical procedures involving
two surgeons, of the same specialty, performing separate
procedure simultaneously.
Using Modifier 62Be sure:
• When billing the surgical procedure with modifier 62, make sure the
documentation of the medical necessity for two surgeons is there
• There is an Indicator of 1- supporting documentation is required to
establish medical necessity of two surgeons for the procedure
• Or Indicator of 2 - the payment rule for two surgeons apply
• Both surgeons append modifier 62 on their claim
• Procedure code and diagnosis code should be same
• One doesn’t bill 44204, the other 45395
Using Modifier 62
• Insurance carriers want providers to use 80, or 82 modifier
• Lower payment to provider: rather pay 116% of fee schedule
than 125%
• Less documentation required
• Lowers the risk of having to pay interest on delayed
payments
Colonoscopy Coding• In CY 2015, the CPT instruction changed the definition of an incomplete
colonoscopy to a colonoscopy that does not evaluate the entire colon. (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4153CP.pdf)
• The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”
• With that change in CPT Manual language, the CMS values in the Medicare physician fee schedule for the following codes: 44388-53, 45378-53, G0105-53, and G0121-53.
Colonoscopy Coding
When covered colonoscopy is next attempted and completed,
the colonoscopy will be paid according to payment methodology
for procedure for either screening or diagnostic colonoscopies
incomplete bowel prep – vs.- large mass
Colonoscopy Coding
• HCPCS/CPT Coding
• G0104: Flexible sigmoidoscopy
• G0105: Colonoscopy, individual at high risk
• G0106: Barium enema –alternative to G0104
• G0120: Barium enema –alternative to G0105
• G0121: Colonoscopy, individual at low risk
• G0122: Barium enema
(noncovered)
• Use when screening barium
enema is not performed as an
alternative to G0104 or G0105
• G0328: Fecal occult blood test
• 81528: Cologuard™ test
• 82270: Fecal occult blood test, 1–
3 simultaneous determinations
Colonoscopy Coding
• Diagnosis Coding
• Z12.11 – Screening for colon cancer
• Z12.12 -for Cologuard Test
• R19.5 – Other Fecal Abnormalities
Colonoscopy Coding
• 2019 Cut in payment
• Watch for billing of multiple colonoscopy techniques in one
session
• Incomplete scopes
• Diagnostic / Therapeutic or Screening
• Because Cologuard testing is indicated in the screening
guidelines, it is considered the screening.
New For 2019
Replacement of gastrostomy tube – 43760
CMS identified code 43760, Change of gastrostomy tube,
percutaneous, without imaging or endoscopic guidance, as a
procedure that could be more complex and require more work
New for 2019
REPLACEMENT CODES