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Learn to code for robotic-assisted surgery, as new technologies become more commonplace

JustCoding News: Inpatient, June 23, 2010

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

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 and other 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 hospitals or surgeons when they perform robotic procedures, so it’s important to obtain pre-authorization from third-party payers and insurance carriers prior to surgery. In come cases, patients may be willing to pay for the surgery out of pocket if their insurance policy does not cover robotics or investigational surgeries.

Currently, surgeons use the daVinci and ZEUS assisted robotic systems for many different surgical procedures across multiple specialties. Use the following ICD-9-CM procedure codes, which CMS introduced in 2008, to identify procedures performed with robotic assistance:

• 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)

According to instructions in the 2010 ICD-9-CM Manual, chapter 17, coders should code first the primary procedure code in addition to the aforementioned robotic codes.

Consider the following procedures (not an all-inclusive list) that surgeons currently perform with a robotic assisted surgical system:

Urologic procedures

• Cyctectomy (57.6, 57.71–57.79)
• Partial nephrectomy (55.4)
• Radical/complete nephrectomy (55.51–55.54)
• Pyeloplasty (55.87)
• Radical prostatectomy (60.5)

General surgery procedures

• Gastric bypass (44.31–44.39)
• Low anterior resections (48.62–48.63)
• Pulmonary lobectomy (32.3–32.49)
• Cholecystectomy (51.21–51.24)
• Nissen fundoplication (44.66)
• Splenectomy (41.43–41.5)
• Adrenalectomy (07.22–07.3)
• Appendectomy (47.01–47.19)
• Hernia repair (53.00–05.9, 17.11–17.24)

Gynecologic procedures

• Hysterectomy (68.31–68.9)
• Myomectomy (68.29)
• Sacrocolpopexy (70.78–70.95)

Cardio/thoracic procedures

• Mitral valve repair (35.23–35.24)
• Revascularizations (36.39 or per operative note designation)

Head/Neck procedure

• Thymectomy (07.80–07.99)

Orthopaedic procedure

• Total hip replacement (00.70–00.73, 00.85–00.87, 81.51–81.53)
• Total knee replacement (00.80–00.84, 81.54)

Gynecologic and urologic surgeries are the most common surgical procedures physicians perform with MIS procedures. Physicians perform both MIS-assisted prostatectomies and MIS-assisted hysterectomies, which are two very different procedures, with nearly the same five small one-quarter inch 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 can perform MIS procedures in an outpatient setting with a 24-hour stay or as in an inpatient setting with a length of stay of one to two days. Note that coders need to be diligent in determining the appropriate place of service code to coordinate with the length of stay.

Click here to access an example of an operative report for a MIS procedure and the appropriate coding for that case.

Editor’s note: Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, is an independent consultant in Melba, ID. E-mail her at LORIWEBB@sarmc.org.

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