CPT Code Description Appendectomy Code Family

44950 Appendectomy

44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure)

44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis

44970 Laparoscopy, surgical, appendectomy When any single or multiple physician or other health care professional reports a code from the Once in a Lifetime Procedures list, that code or any code from the same Code Family will be reimbursed only once during a patient’s lifetime. In the appendectomy example, a single code from the Appendectomy Code Family will be reimbursed only once during a patient’s lifetime, because each person has only one appendix and can have only one appendectomy during his or her lifetime.

REIMBURSEMENT GUIDELINES

Oxford will reimburse certain procedures only once during a patient’s lifetime. Once in a Lifetime Procedures are not limited to a single CPT code, but may be represented by Code Families, which are a group of CPT codes that describe the same or similar type of service. Under this policy, Oxford provides reimbursement for only one procedure from a designated Code Family during a patient’s lifetime.

For example, there are four separate appendectomy CPT codes that can be used, based upon the particular circumstance, to report the removal of the appendix. The four codes, listed below, make up the Code Family that describes the removal of an appendix.






Modifiers

There may be situations that require the code(s) for a Once in a Lifetime Procedure to be submitted more than once during a patient’s lifetime. In such cases, more than one Once in a Lifetime Procedure, whether the same code or a different code from the same Code Family will be considered separately for reimbursement if reported with one of the following modifiers:

Modifier Description

53 Discontinued procedure

55 Postoperative management only

56 Preoperative management only

58 Staged or related procedure or service by the same physician

For additional information related to the percentage of the allowable fee to be paid when one of these modifiers is appended to a claim for a subsequent procedure, please refer to the Discontinued Procedure policy, Split Surgical Package policy and/or Global Days policy.

DEFINITIONS

Code Family: A group of CPT codes that describe the same or similar type of service.

Once in a Lifetime Procedure: A procedure that can be performed by a physician(s) or other health care professional(s) only once in a patient’s lifetime.




QUESTIONS AND ANSWERS

Q: Would there ever be an instance where a CPT code for a Once in a Lifetime Procedure may be reported more than once?

A: Yes, there are instances where a CPT code for a Once in a Lifetime Procedure may be reported more than once. Modifiers may be used to indicate a procedure or service has been altered in some way, but not changed in its actual code description. For example, by definition, modifier 53 (Discontinued Procedure) is to be used when a procedure is terminated for unforeseeable circumstances. Per coding guidelines, the procedure code would be initially reported with modifier 53 appended to the CPT code to indicate the discontinued procedure and then at a later time, the CPT code would be submitted again when (if) the procedure took place in its entirety.

2 Q: How is a Once in a Lifetime Procedure reimbursed when reported by two different physicians on different dates of service?

A: When any physician or other health care professional reports a code from the Once in a Lifetime Procedures policy list on multiple dates of service excluding the same date of service, the code will be reimbursed only once. Oxford follows a “first in, first out” claim payment methodology in determining which claim will be considered for reimbursement when duplicate claims are received.


3 Q: What if two different physicians each report the same procedure on the same date of service for the same patient from the Once in a Lifetime Procedures list? 

A: The Once in a Lifetime procedure codes are subject to duplicate billing when reported by the same or different providers.