Elective laparoscopic appendectomy in gynecologic surgery: When, why, and how

Coding for appendectomy is fairly straightforward if you know the rules, but prophylactic removal of the appendix, whether performed at the time of a laparoscopic or open abdominal primary procedure, will usually lead to reimbursement difficulties for surgeons even though CPT codes exist to report the procedure. Knowing when and how to bill and document the circumstances for removal will go a long way in getting payment for the procedure. Note that these rules apply to a single surgeon who is performing the entire surgery. When an ObGyn is performing gyn procedures, but a general surgeon is the one who removes the appendix, that surgeon will not be subject to bundling rules, but will still have to make a case with the payer for removing an otherwise normal appendix.

There are 5 codes that can be used to report an appendectomy:

• 44950 Appendectomy;
• 44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure)
• 44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis
• 44970 Laparoscopy, surgical, appendectomy code
• 44979, Unlisted laparoscopy procedure, appendix.

Code 44950 represents either a stand-alone procedure or an incidental appendectomy when performed with other open abdominal procedures. Under CPT guidelines this code would only be reported 1) when this is the only procedure performed and the appendix is removed for a diagnosis other than rupture with abscess, or 2) with a modifier -52 added if the surgeon believes that an incidental appendectomy needs to be reported. Use of a modifier -52 will lead to review of the documentation by the payer, and it will be up to the surgeon to convince the payer that he should be paid for taking out an appendix that is found to be normal. Billing 44950 with other abdominal procedures without this modifier will lead to an outright denial due to bundling edits, which permanently bundle 44950 with all major abdominal procedures.

Code 44955 is the code to report when an appendectomy is performed for an indicated purpose at the time of other open abdominal procedures. For instance, the appendix may have been removed due to a finding of distention with fecalith or extensive adhesions binding the appendix to the abdominal wall. When this code is reported, no modifier is used because it is a CPT “add-on” code that can only be billed in conjunction with other procedures.

Code 44960 is only reported when no other open abdominal procedures are performed at the operative session and the reason for taking out the appendix is rupture with abscess. If rupture is found at the time of an abdominal procedure to remove a mass, for instance, code 44955 would be reported instead.

Code 44970 is the only laparoscopic approach code for an appendectomy, but it would only be reported when 1) the appendectomy was the only laparoscopic procedure performed, or 2) the appendectomy was incidental, but the surgeon felt it needed to be reported. There is no instruction about using a modifier -52 with 44970 to report an incidental appendectomy. According to the American Medical Association’s January 2012 issue of CPT Assistant, laparoscopic removal of the appendix for an indicated purpose at the time of another major laparoscopic procedure should be reported as 44979, Unlisted laparoscopy procedure, appendix.

Keep in mind that code 44970 is bundled into a long list of laparoscopic procedures, including codes for treating stress urinary incontinence and prolapse (CPT codes 51990–51992, 57425), sterilization procedures (CPT codes 58670–58671), hysterectomy procedures (CPT codes 58541–58544, 58548, 58550–58554, 58570–58573), myomectomy procedures (CPT code 58545–58546), as well as codes for lysis, removal of lesions and ovaries, or aspiration of lesions (CPT codes 49321–49322, 58660–58662). A modifier -59 (Distinct Procedural Service) can be reported to bypass these edits, but the payer will request documentation to ensure that the criteria for using this modifier apply. The CPT criteria include documentation of a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) which is not ordinarily encountered or performed on the same day by the same individual. Failure to discuss the reason for the removal in the body of the operative report will generally mean the payer will deny extra payment for the appendectomy.

—MELANIE WITT, RN, CPC, COBGC, MA

Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.