Modifier 22 Could Help Save This Lap-to-Open Gyn Surgery

laparoscopic gynecological procedure

Whether to code lysis of adhesions during a gynecological procedure is a question that comes up again and again.

I’ve talked before about how removing adhesions is generally an expected part of the procedure, but exceptional cases may merit the use of modifier 22 (Increased procedural services) on the surgery code.

A new take on this question is how to handle coding for a surgery that converts from laparoscopic to open because of adhesions. Here’s an example from Ob-Gyn Coding Alert with some bonus tips straight from the National Correct Coding Initiative manual (NCCI manual or CCI manual, for short).

Start With This Sling Example

Consider the example of an ob-gyn surgeon who begins a laparoscopic sling procedure described by 51992 (Laparoscopy, surgical; sling operation for stress incontinence [e.g., fascia or synthetic]).

The surgeon tries to remove massive adhesions affecting the bowel, pelvic sidewall, fallopian tubes, and ovaries. The documentation describes the adhesions as extensive, dense, very adherent, and containing a blood supply. After an hour, the surgeon decides that converting the surgery to an open procedure is the best decision for the patient. The correct code for the open procedure is 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). (By the way, have any of you ever wished CPT® would update code descriptors like 57288 to include the term “open” when that’s what the code represents? There’s a word for that sort of change: retronym.)

Here Are the General CCI Rules

Chapter I: The first chapter of the CCI manual covers General Correct Coding Policies.

Chapter 1, Section B, Coding Based on Standards of Medical/Surgical Practice, lists lysis of adhesions as one of the services integral to a large number of procedures.

Translation: It’s not surprising that CCI edits bundle lysis codes into so many surgeries.

Section C, Medical/Surgical Package, addresses the issue of coding for laparoscopic procedures converted to open procedures in subsections 10 and 11:

  • 10. “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported.”
  • 11. “If a laparoscopic procedure fails and is converted to an open procedure, the physician should not report a diagnostic laparoscopy in lieu of the failed laparoscopic procedure.”

Translation: If a laparoscopic approach fails and the surgeon switches to an open procedure to complete the surgery, then you should report only the open procedure. And don’t try to get around the rule by coding the lap work as a diagnostic service.

Chapter VII: The seventh chapter applies to surgery codes in the 50000-59999 range, including female genital surgery. Section F, Laparoscopy, subsection 4, supports what the first chapter had to say.

  • 4. “If a laparoscopic procedure fails and is converted to an open procedure, only the open procedure may be reported. Neither a surgical laparoscopy nor a diagnostic laparoscopy code should be reported with the open procedure code when a laparoscopic procedure is converted to an open procedure.”

Full disclosure: If the lap service was truly diagnostic, CCI applies a different rule. According to Section F.1, “If a laparoscopy is performed as a ‘scout’ procedure to assess the surgical field or extent of disease, it is not separately reportable. If the findings of a diagnostic laparoscopy lead to the decision to perform an open procedure, the diagnostic laparoscopy may be separately reportable.” You may use modifier 58 (Staged or related procedure …) in those cases, the manual says. “The medical record must indicate the medical necessity for the diagnostic laparoscopy.”

Apply the Rules to Our Case

We know the correct code to report for our encounter is the open procedure code 57288. Based on all of our CCI pointers listed above, you can’t report laparoscopic procedure code 51992 for this lap-to-open surgery, so your best option for reporting the intense laparoscopic work is to append modifier 22 to 57288.

Using modifier 22 is sure to trigger a manual review by the payer, so check the documentation you submit to confirm it clearly shows the unusually difficult nature of the case and compares the time and work this case required to the time and work a typical case requires.

How About You?

What are your tips for submitting modifier 22 claims that get paid and meet compliance rules?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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