Split Thickness Skin Graft

Question:

Please resolve an internal debate we’re having in our office. Are the STSG codes chosen based on the recipient or the donor site?

Answer:

Good Question:, and this is always confusing. CPT says: “Select the appropriate code from 15040-15261 based upon type of autograft and location and size of the defect. The measurements apply to the size of the recipient area.” So you’ll choose the code based on the recipient/defect site and the area (in square centimeters) is of that same site. The two STSG graft codes are 15100 (recipient/defect site is trunk, arms or legs) and 15120 (recipient/defect site is face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits).

*This response is based on the best information available as of 12/03/15.

Endoscopic Skull Base Surgery

Question:

We are thinking about starting an endoscopic skull base surgery program and doing skull base procedures via an expanded endonasal/endoscopic approach. I’ve looked in the CPT book for codes and it looks like CPT 61580-61619 are just what I’m looking for. Is this correct?

Answer:

That’s great that you’re starting a new program! And, we can help. There is one CPT code for an endoscopic skull base procedure – 62165, Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach. However, other procedures that you’ll do such as an endoscopic resection of a clival chordoma are not accurately coded using 61580-61619, as these existing codes are for open procedures. We wrote an article for the AAO-HNS Bulletin about this a few years ago that I think you’ll find helpful. Here are the links:

Sample Prior Authorization, Cover Letter, or Appeal Letter for the Otolaryngologist’s Use of an Unlisted CPT Code for Endoscopic/Endonasal Skull Base Surgery

Coding and Reimbursement Strategies: Using an Unlisted Code for Endoscopic Skull Base Surgery

*This response is based on the best information available as of 12/03/15.

Removal of Spinal Cord Stimulator

Question:

My doc removed an electrode plate previously placed via laminectomy – 63662. At the same time, he removed the pulse generator – 63688. Is the removal of the generator considered a secondary procedure and therefore reduced in reimbursement by 50%?

Answer:

Yes, that’s correct. CPT 63662 is the higher valued code so it should be paid at 100% of the payer allowable. The generator removal, 63688, is the lower valued code and CPT says to report it with modifier 51 (multiple procedures).

Therefore, 63688 will typically be reduced by the payer’s multiple procedure payment formula (MPPF). Medicare’s MPPF is 50% for secondary stand-alone procedures.

*This response is based on the best information available as of 12/03/15.

Coding Incomplete Colonoscopies

Question:

Which code would be appropriate to report45330, Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) or45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), if the physician is unable to advance the colonoscope to the cecum?

Answer:

Per CPT guidelines, if the colonoscopy was a screening or diagnostic colonoscopy, CPT code45378would be reported with modifier 53, Discontinued Procedure. This indicates that a diagnostic or screening was not complete to the cecum. If the colonoscope does not reach the splenic flexure, a sigmoidoscopy, code45330, would be reported.

If the colonoscopy was therapeutic and it is not complete to the cecum, the appropriate therapeutic colonoscopy code is reported with a 52 modifier.

Refer to the decision tree in the CPT Professional codebook.

*This response is based on the best information available as of 12/03/15.

Infected Knee

Question:

Will you please direct this question to Mary LeGrand? I was consulted to evaluate a patient to rule out a septic knee. I saw the patient in the morning and aspirated the joint; the fluid was cloudy and sent to pathology. Later that day I was notified of an increased cell count and decided to take the patient to the OR later that day for an arthrotomy with lavage. My coder is telling me that I cannot bill CPT code 20610 with the arthrotomy because of a Medicare payment edit. This makes no sense to me. Can you advise if I am able to report this aspiration or not?

Answer:

Thanks for your inquiry. Yes, the aspiration is reportable with CPT code 20610 as you note. You may also report the arthrotomy with knee lavage; for example, CPT code 27310. Your coder is correct in that an NCCI edit is present between the two codes when performed on the same knee, same session. However, in your scenario, they are performed same day, different sessions. Append a modifier 59 (distinct procedure) to CPT code 20610 to indicate the aspiration occurred at a different session on the same day. If your Medicare carrier has instructed to use the new “X” modifiers instead of modifier 59 to indicate the “separate encounter,” you would report 20610 XE instead of 20610-59.

Your service will be reported one of two ways:2731020610-59Or2731020610 XE

*This response is based on the best information available as of 10/08/15.

Medicare: Debridement Services in the Shoulder

Question:

We attend courses and receive education from KZA consistently on orthopaedic coding. Our practice recently hired a new billing manager and she states that the information we have been given is incorrect for Medicare related to arthroscopic debridement services. The billing managers external resource told her that 29822 or 29823 can be reported with other arthroscopic shoulder services as long there is no NCCI edit in place. We are telling the new manager that this is incorrect for Medicare.

Can you please help validate what we perceived we heard from KZA is correct? To re-state, our question evolves around reporting debridement services (CPT codes 29822 and 29823) to Medicare when the patient has other arthroscopic shoulder procedures on the same shoulder. We understood, and have told the new billing manager, that the debridement services are considered inclusive to other arthroscopic procedures performed and reported on the same day if the debridement services are performed on the same shoulder. Our manager is telling us that if there is no edit in place, for example with CPT code 29826 and 29822, that we can report both to Medicare. Again, for clarification, she cites a non-KZA resource person.

Answer:

Thanks for your loyalty and reaching out. Based on the information provided, you accurately perceived the instructions for reporting arthroscopic shoulder procedures to Medicare. While there are no NCCI edits between some of the arthroscopic procedures and either CPT code 29822 or 29823, it is considered incorrect coding to report one of these debridement codes in addition to other arthroscopic shoulder procedures performed on the ipsilateral or same shoulder. One common error in coding according to Column 1 and Column 2 code edits is assuming if there is no edit, that the code combination may be reported together.

The following source information used by KZA in all orthopaedic instructions is found in the January 2015 NCCI Musculoskeletal Chapter 4:“4. With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter. For knee joint arthroscopic debridement see the following paragraph.”

While a Column 1 or Column 2 edit may not exist in the Excel database, these written guidelines provide additional coding information in addition to the Column 1 and Column 2 edit. CPT codes 29822 or 29823 are not reportable with other arthroscopic shoulder procedures on the same shoulder, same session.*This response is based on the best information available as of 09/24/15.