E&M Coding Based on Time

Question:

When choosing the level of E&M we are confused about the History and Exam. If we choose a level of E&M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E&M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (eg, review of tests);
• obtaining and/or reviewing separately obtained history;
• performing a medically appropriate examination and/or evaluation;
• counseling and educating the patient/family/ caregiver;
• ordering medications, tests, or procedures;
• referring and communicating with other health care professionals (when not separately reported);
• documenting clinical information in the electronic or other health record;
• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and
• care coordination (when not separately reported).

source: CPT Assistant April 2022

*This response is based on the best information available as of 01/19/23.

Counting Laminectomy Levels

Question:

I am confused and hoping you can clarify a coding question I have. I thought I understood how to report laminectomy levels, however, after recently reading an article in the AHA Coding Clinic HCPCS Volume 22, Number 2 Second Quarter 2022 publication, I doubt myself. The surgeon performs and documents a L2, L3, L4 laminectomy with decompression (lateral recess). I have always coded this as 63047, and one unit of 63048. The coding publication I was reading states to report 63047 and 2 units of 63048. Have I been coding incorrectly by only reporting one unit of 63048?

Answer:

Thank you for contacting KZA for clarification. We understand your concern when reading various publications and seeing articles that are not consistent with what you thought you knew.

Without seeing an actual operative note, we agree with how you have coded this type of case in the past. Let’s take a look why.

CPT code 63047 is defined as “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)),single vertebral segment; lumbar”

A “vertebral segment” means per motion segment. The decompression of the existing nerve root is performed in the interspace between the two lamina.

L2, L3, L4 when looked at closely defines two motion segments:

L2-3 =63047

L3-4= 63048 x 1 unit.

To report a third unit of 63048, the surgeon would either have had to go “up a level” to L1-L2, or “down a level” to L4-5.

We appreciate your verifying your coding practices.

*This response is based on the best information available as of 12/15/22.

Foreign Body Removal

Question:

A patient had a craniotomy a week ago and the provider is doing a removal of a retain drain of post op wound in the operating room. What is the best code to use 10120?

Answer:

The best code is 10121, incision and drainage of foreign body, complex, since this required a return to the OR and was done for retained cranial drain. Remember to add a 78 modifier, for a return to the OR.

*This response is based on the best information available as of 12/01/22.

Counting Laminectomy Levels

Question:

I am confused and hoping you can clarify a coding question I have. I thought I understood how to report laminectomy levels, however, after recently reading an article in the AHA Coding Clinic HCPCS Volume 22, Number 2 Second Quarter 2022 publication, I doubt myself. The surgeon performs and documents a L2, L3, L4 laminectomy with decompression (lateral recess). I have always coded this as 63047, and one unit of 63048. The coding publication I was reading states to report 63047 and 2 units of 63048. Have I been coding incorrectly by only reporting one unit of 63048?

Answer:

Thank you for contacting KZA for clarification. We understand your concern when reading various publications and seeing articles that are not consistent with what you thought you knew.

Without seeing an actual operative note, we agree with how you have coded this type of case in the past. Let’s take a look why.

CPT code 63047 is defined as “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)),single vertebral segment; lumbar”

A “vertebral segment” means per motion segment. The decompression of the existing nerve root is performed in the interspace between the two lamina.

L2, L3, L4 when looked at closely defines two motion segments:

L2-3 =63047

L3-4= 63048 x 1 unit.

To report a third unit of 63048, the surgeon would either have had to go “up a level” to L1-L2, or “down a level” to L4-5.

We appreciate your verifying your coding practices.

*This response is based on the best information available as of 11/17/22.

Coding for Trigeminal Neuralgia #3

Question:

How is RFA rhizotomy of the trigeminal nerve at the second and third division branches of the foramen ovale reported ? The diagnosis was Trigeminal Neuralgia.

Answer:

This procedure is coded as 64605, Destruction by neurolytic agent, trigeminal nerve second and third division branches at foramen ovale .Code +77002 may also be reported if fluoroscopy is used, documented, and a permanent image is retained.

*This response is based on the best information available as of 11/03/22.

Coding for Trigeminal Neuralgia #2

Question:

How is percutaneous ganglion balloon compression rhizotomy of the trigeminal nerve reported? The diagnosis was Trigeminal Neuralgia.

Answer:

This procedure is reported with an unlisted code, 64999. There is no CPT code for this percutaneous procedure.

*This response is based on the best information available as of 10/20/22.