Spring 2016  

Coding and Reimbursement Updates

By Steven Sentovich, MD; William Harb, MD; Guy Orangio, MD; and the Healthcare Economic Committee

Code 46707 Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa [SIS])
This code was converted from a CPT Category III code to a Category I code and was first published in the 2010 Current Procedural Terminology, the only official CPT codebook, copyright American Medical Association (AMA). CPT 46707 has a Work RVU of 6.39, and is well-placed in the family of codes under the category of repair of anorectal fistula.

However, since it has become a Category I code, the American Society of Colon and Rectal Surgeons’ (ASCRS) Health Economics Committee has received many inquiries and complaints from members that insurance companies have denied payment. Key Point: just because a procedure has a Category I code, it does not guarantee payment. The majority of our procedures require prior authorization from the insurance company before we perform a procedure. This prior authorization also does not guarantee payment.

A reasonable approach for the surgeon to receive payment is to speak to the medical director of the insurance company and discuss the clinical problem in advance of the standard preauthorization process. This conversation allows the surgeon to support the decision to utilize the 46707 code for the patient, while discussing the alternative procedures that would have to be utilized if the 46707 code is not authorized: for example, endoanal advancement flap or LIFT procedures, both of which have a higher morbidity and cost. This dialogue will educate the medical director on the complex decision making for treating anorectal fistula and possibly “insure” reimbursement.

The Minimally Invasive Transanal Total Mesorectal Excision (TaTME)
As with any procedure performed, physicians want to be reimbursed for their work. The issue is what are the correct codes for billing for this procedure?

The following figures and tables will explain correct coding for this technically demanding procedure. The following tables are a compilation of the Category I CPT codes utilized for open and minimally invasive approaches to low/ultra low rectal resection with anastomosis and APR with colostomy. The following are the open CPT Codes with the long descriptors from the CPT Professional Edition.

Figure I: Laparotomy Codes (Open Codes)
44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis)

44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) with colostomy

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

Table I*

CPT Category I Code Last Review by RUC WRVU CMS Reimbursement ($) Claims Data
(2014)
Primary Provider (%)

41145

02/2006 28.58 1,716.23 7,328 GS 66.13
CRS 23.19
44146 02/2006 35.30 2,197.84 1,318 GS 64.34
CRS 26.40
44147 02/2006 33.69 2,013.35 402 GS 80.60
CRS 16.42
45112 02/1994 33.18 1,948.63 173 CRS 52.60
GS 34.10
45119 08/2000 33.48 2,019.78 99 CRS 64.65
GS 29.29
45110 08/2000 30.79 1,913.23 1,404 GS 47.08
CRS 44.94

Figure II: Laparoscopic Codes (Minimally Invasive Codes: Pure Laparoscopic, Hand Assisted and/or Robotic applications)
44207 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis)

44208 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy

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

Table II*

CPT Category I Code Last Review by RUC WRVU CMS Reimbursement ($) Claims Data
(2014)
Primary Provider (%)

44207

04/2002 31.92 1,887.13 7,810 GS 57.13
CRS 39.39
44208 02/2002 33.99 2,061.62 610 CRS 36.89
45395 02/2005 33.00 2,050.53 787 CRS 57.43
GS 37.23
45397 02/2005 36.50 2,232.88 213 CRS 66.20
GS 31.92

*Key: The columns defined in both Table I & II: CPT code, the last time it was reviewed by the AMA/Specialty Society Relative Value Update Committee (RUC), the current Work RVU, CMS reimbursement (this will vary by region of US) the number of times it was utilized in the Medicare population and the primary provider (GS is General Surgery, CRS).

Principals: 1) The following open codes 44147, 45112, 45119, 45110 and laparoscopic codes 44395 & 44397 have the term “combined abdominoperineal” approach, this means that the code cannot be “unbundled” in to two separate procedures, nor billed separately even if two separate surgeons do a particular part. The first assistant codes apply.

2) Adding a 62 Modifier to a code does not permit separate billing of an already “bundled” procedure. The first assist codes apply.

3) Unbundling is considered “billing fraud.”

Billing Recommendations for the TaTME Procedure:
Utilize the existing Laparoscopic CPT Codes in Table II, for billing the utilization of this procedure.

 
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