Robotic Assisted Surgery - New Technologies

I know a lot of you are struggling with how to code for robotic assisted surgery. Inpatient facility coders have the "luxury" of using the ICD-9 procedure codes which are much more descriptive and really "tell the story"... but coding for physician fees with CPT, it is much more difficult. Below, I've tried to explain what robotic coding is, the types of surgeries currently being done with robotic assist, then how to code them out. Hopefully, this will help you out.... and as always... If you have questions, or need additional assistance with these, please e-mail me .... L : )

Robotic-assisted surgery, also known as “minimally invasive surgery” (MIS), has become almost commonplace in hospital operating suites throughout the United States, predominantly with the daVinci^® robotic system or the ZEUS^® robotic system.

The use of robotics in surgery continues to evolve, and this poses challenges for hospitals and providers to stay abreast of these changes. In turn, coders may also struggle to stay current in terms of how to code for these procedures.

The pros and cons of robotic-assisted or MIS systems are well documented. The biggest pro of MIS systems is that they allow surgeons to execute exact surgical micro-movements of the robotic instrument as a laparoscopic procedure. The daVinci^® also includes 3D images and the ability to rotate the instruments 360 degrees. The biggest con to the robotic systems is the purchase price plus all the specialty specific tools / add-ons necessary to outfit the surgical suite

In addition to cost of the equipment, robotic procedures also require longer operating room time and turn around time, as well as qualified physicians and operating room staff who are educated in how to use the robot. Some third-party insurance payers consider MIS surgery “investigational" and will not reimburse the hospital or the surgeon if a robotic procedure is performed. So it’s important that 3rd party payer/insurance carrier pre-authorization has been done, and determined prior to surgery. In some cases, the patient may be willing to pay for the surgery out of pocket if their insurance policy does not cover robotics or investigational surgeries.

Currently, gynecologic and urologic surgeries are the most common surgical procedures physicians are performing with MIS. Physicians perform both MIS-assisted prostatectomies and MIS-assisted hysterectomies, which are two very different procedures, with nearly the same five small ¼” incisions instead of the usual open or laparoscopic incisions.

Robotic-assisted surgical procedures also allow patients to have shorter lengths of stay in the hospital. Normally patients who undergo these procedures without the robotic assistance have a length of stay of three to five days. But physicians performing these procedures with the MIS patients routinely have a length of stay of one to two days. (**Note that coders need to be diligent in determining the appropriate place of service to coordinate with the length of stay)

Currently, surgeons use the daVinci^® and ZEUS^® assistive robotic systems for many different surgical procedures across multiple specialties.

For inpatient coders, use the following ICD-9-CM-3 procedure codes, (which CMS introduced in 2008) to identify procedures performed with robotic assistance.

According to the ICD-9CM-3 Chapter 17 instructions: inpatient coders are to code the primary procedure codefirst, the add the robotic code(s) as a secondary code. The list below identifies the robotic codes –

• 17.41 (open robotic assisted procedure)
• 17.42 (laparoscopic robotic assisted procedure).
• 17.43 (percutaneous robotic assisted procedure)
• 17.44 (endoscopic robotic assisted procedure)
• 17.45 (thoracoscopic robotic assisted procedure)
• 17.49 (other and unspecified robotic assisted procedure)

Below lists the primary procedures (not an all-inclusive list) that surgeons are currently performing with a robotic MIS:

Urologic

· Cyctectomy

· Partial nephrectomy

· Radical/complete nephrectomy

· Pyeloplasty

· Radical prostatectomy

General surgery

· Gastric bypass

· Low anterior resections

· Pulmonary lobectomy

· Cholecystectomy

· Nissen fundoplication

· Splenectomy

· Adrenalectomy

· Appendectomy

· Hernia repair

Gynecologic

· Hysterectomy

· Myomectomy

· Sacrocolpopexy

Cardio/thoracic

· Mitral valve repair

· Revascularizations

Head/Neck/thyroid

§ Thymectomy

Orthopaedic

§ Total hip replacement

§ Total knee replacement

In regard to professional fees (Physician fees) and billing, CPT has lagged behind in getting codes to reflect MIS. CPT does not currently have any codes specifically designated for “robotic” assistance. If the surgeon is performing procedures with a robotic assist , you are directed to code the “nearest” code for what the surgeon performed. Depending on what the surgeon documented, you should use the code-set for open, laparoscopic, or unlisted code (s) , then add HCPCS code S2900.

HCPCS code S2900 is ONLY for use with private payors, and not applicable for Medicare/Medicaid/Tricare claims. In addition include in the notes section of your claim, " "procedure performed with a robotic surgical assist device". Also.. DO NOT APPEND MOD 22, 59, or 52. Keep your pricing the same as it would be if done as a traditional laparascopic or open procedure.

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Below outlines the CPT codes for the Uro and GYN procedures that are the most common..

Robotic-Assisted Radical Prostatectomy Coding and Reimbursement:

CPT-55866

Laparoscopy, surgical prostatectomy, retropubic, radical, including nerve sparing

CPT-55899

Unlisted procedure, male genital system

Coding and Reimbursement – Gynecology via the da Vinci Surgical System

58541-Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

58542-with removal of tube(s) and/or ovary(s)

58543-Laparoscopy, surgical supracervical hysterectomy, for uterus greater than 250 g

58544-with removal of tube(s) and/or ovary(s

58548-Laparoscopy with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed

58550-Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less

58552- with removal of tube(s) and/or ovary(s)

58553-Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g

58554-with removal of tube(s) and/or ovary(s)

58578-Unlisted laparoscopy procedure, uterus

Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA,

webbservices.lori@gmail.com.

Prolonged Services - A Quick Refresher!!!

This was info passed along to me from Gail E. in Boise... Thanks so much!


Prolonged Services

CPT codes 99354-99357 are designated within the CPT code set as add-on codes. The codes in this series are used to report the provision of prolonged physician service that involves direct (face-to-face) patient contact beyond the usual service (ie, beyond the typical time) in either the inpatient or outpatient setting. The term face-to-face is defined as only that time that the physician spends in direct, face-to-face contact with the patient. It is appropriate to report this service in addition to other physician services, including evaluation and management (E/M) services at any level. Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period.

99354-Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)

99355each additional 30 minutes (List separately in addition to code for prolonged physician service)

99356-Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (List separately in addition to code for inpatient Evaluation and Management service)

99357 each additional 30 minutes

Example 1. - Provider spends a total of 2 hours with a patient counseling on such issues as depression, ADHD, medication side effects or providing an office visit with a patient through an interpreter. The majority of the visit content was counseling.
Coding would be 99215 (40 minutes)
99354 (1st hour of prolonged services)

Example 2. – Provider sees a patient in the Labor and Delivery unit of a hospital and provides prolonged observation and fetal monitoring. Total time spent with the patient was 2 hours- A minimal exam and history are taken.
99213 (15 minutes)
99354 (1st hour of prolonged services)
99355 (additional 30 minutes of prolonged services


• Total visit time must be documented to bill these services
• Remember to document in and out times

Medicare transmittal 1490 released April 11, 2008 clarifies that all prolonged service time must be face to face for Medicare patients