Questions to consider
The base concept of the intraoperative surgical package includes all necessary aspects of the procedure or service as described by the CPT definition. We have summarized this concept by asking the following two general questions:
Was the service provided required for the billed service? Examples include:
• Was a laparotomy required to remove the lymph nodes that were sent for frozen section during an open lymphadenectomy?
• Was lysis of adhesions required to safely and adequately remove the kidney?
• Was visualizing the entire bladder to make sure all the bladder tumors were resected expected medical practice?
Is there a CPT code that describes everything we did for the patient? Examples include:
• Is there a code that includes radical nephrectomy and removal of thrombus from vena cava?
• Does the code indicate that it should be reported for each tumor removed?
If the answer to either or both of these questions is yes for a majority of cases and providers, then all the services should be considered as bundled into the appropriate code or codes selected and no additional codes should be reported.
We encourage you all to be diligent, accurate, and honest in answering these questions. Over the years, we have seen many examples of missing this concept in over- and under-reporting. A few examples include:
• not reporting prostatectomy with a cystectomy
• reporting urethropexy with robotic prostatectomy for simple closure and repair after removal of prostate
• reporting vaginoplasty with cystocele repair for simple closure of vaginal wall.