Endoscopic Procedures Medical Billers and Coders Encounter

By Karen Smiley

Many surgical procedures that you code are performed through the use of scopes. This type of procedure is generally referred to as minimally invasive surgery. Some operations can be completed entirely through a scope, while others are assisted by the use of a scope but still involve making an incision.

Some of the most common scope procedures are arthroscopic surgeries and laparoscopic procedures. The following sections have the details.

Looking at arthroscopy

Arthroscopic surgery allows orthopedic surgeons to visualize, diagnose, and possibly treat injury or disease inside of a joint.

When a procedure is performed arthroscopically, the surgeon makes a minimum of three small incisions, called portals, into the joint. One incision is for visualization, one is for infusion of liquid for joint spaces, and the third is for the instruments, which are much smaller than traditional surgical instruments.

Rather than directly view the surgical field (the area being operated on), the surgeon uses the scope to view the inside of the joint on a monitor. To make viewing the area easier, the joint is inflated with fluid, and additional portals may be created to view other areas within the joint.

Common arthroscopic procedures are performed on knees, shoulders, ankles, and hips. Small joints are also treated arthroscopically, but these procedures, such as carpal tunnel release, are less common and often are more time‐consuming than traditional surgeries.

Scoping out families

The American Medical Association (AMA) and American Academy of Orthopedic Surgeons (AAOS) categorize arthroscopic procedures into scope families. Simply put, scope families are procedures that go together.

Certain procedures are inherent to (automatically part of) other procedures that are performed. Because inherent procedures don’t require additional time or skill by the surgeon, they’re not eligible for additional reimbursement.

Here’s an example of a scope family procedure: arthroscopic chondroplasty inside the knee. The knee has three compartments: medial, lateral, and patello‐femoral. Normally, the surgeon views all three compartments during a knee scope. Even if he shaves in each of the three areas, you can bill only one chondroplasty.

Different procedures that are performed in different compartments may be billable, depending on the documentation and the individual coding requirements for each compartment. The AMA and AAOS define what is separately billable and what is not. If you find yourself working in orthopedics, you need to learn what is and isn’t considered a separate procedure. You can refer to the AMA website and the AAOS website for more information.

Coding arthroscopic procedures

So how would you handle coding such a procedure? You’ve got to start with the documentation. The physician should document the surgery by compartment, clearly stating what he did in each compartment. The CPT book lists the different procedures that may have been performed.

To be eligible for additional reimbursement, each procedure must have been fully documented as having been performed in different compartments. But be sure to check the edits because certain procedures — such as chondroplasty — are not to be separately reported unless they are the only procedures performed.

Sometimes a procedure is begun through a scope and then converted to an open procedure due to complications. When that happens, you code the open procedure only.

Defining laparoscopy

Laparoscopic surgery is a member of the endoscopy family, along with arthroscopy, except that laparoscopic surgery refers to the abdominal cavity (laparo‐ means “abdomen”); laparoscopic surgeries also include surgeries performed in the pelvic cavity.

This type of procedure is another minimally invasive surgery that is sometimes called “Band‐Aid surgery” because the incisions may have a suture, but they’re often simply covered with a small bandage. Common laparoscopic procedures include gallbladder removal, appendectomies, ovarian cyst excisions, and numerous others.

Understanding the procedure

Here’s how laparoscopic surgeries work: Procedures are performed through a set of small portals in the abdomen. Similar to arthroscopic procedures, the physician views the interior of the abdomen on a monitor. During a laparoscopy, the abdomen is inflated with gas, which creates space that makes the areas easier to see and gives the surgeon more room to work.

Common acronyms for laparoscopic procedures are

  • SPA: Single Port Access surgery

  • LESSS: Laparoscopic Endoscopic Single‐Site Surgery

  • SLIT: Single Laparoscopic Incision Transabdominal

  • OPUS: One‐Port Umbilical Surgery

  • NOTUS: Natural Orifice Transumbilical Surgery

  • E-NOTES: Embryonic Natural Orifice Transumbilical Endoscopic Surgery

You will always want to verify documentation for correct code assignment and make certain that you are using current editions of coding materials in the event that a new code was added. For ICD‐10 PCS, the approach is essential to the correct code assignment.

At the beginning of the surgery, the scope is inserted through an incision near the navel, and the surgeon views inside the cavity to make sure that it’s safe to proceed. If, during this inspection, the surgeon sees any medical reasons to stop the procedure (called contraindications), the laparoscopic procedure is converted to a traditional open procedure. Contra‐indications include excessive inflammation or various other unknown risk factors.

If the surgeon feels that proceeding with the laparoscopy is safe, he creates additional portals for the specialized instruments needed to facilitate the necessary procedure(s).

Some procedures are laparoscopically assisted. An example is a hand‐assisted laparoscopic surgery, in which the surgery is performed via a technique that uses a larger portal that allows for the insertion of a hand. This incision is larger than the traditional port but still smaller that a laparotomy incision. Surgeries performed laparoscopically normally require shorter recovery times and have fewer complications, compared to traditional open ­procedures.

Breaking down families of laparoscopy

Laparoscopic procedures that go together are sometimes referred to as families. Procedures that are performed together as part of the necessary procedures may not be separately billable.

One common example in the laparoscopic world is a diagnostic laparoscopy. A physician may determine that the only way to really know what is going on with a patient is to take a look, using a diagnostic procedure. If that’s all the doctor does, then the diagnostic procedure is billable. But if during this look‐see, the surgeon sees something else — say an inflamed appendix — and removes it via laparoscopic appendectomy, then only the appendectomy can be billed.