Dialysis Access Creation in Lower Extremity

Question:

I created an AV access in the leg. What code do I use for this?

Answer:

The CPT codes for AV graft or fistula creation apply to the lower extremity as well as the upper extremity. Take a look at codes 36281- 36830 for the most appropriate code for the procedure you performed.

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WEBINAR ALERT!The codes for AV access/dialysis circuit imaging and interventions all change on January 1, 2017. JoinTeri Romanofor a webinar on these and other new vascular codes on December 14, 2016.

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*This response is based on the best information available as of 12/01/16.

Acromioclavicular Joint Billing

Question:

When our physician performs an injection into the acromioclavicular (AC) joint of a patient in the office, can we bill 20610 for a large joint arthrocentesis? I say yes because it is in the shoulder, which is listed as an example large joint in the code descriptor.

Answer:

No. The correct code to bill in this case would be 20605 for an intermediate joint. Although the AC joint is between the shoulder and the clavicle, it is considered an intermediate joint. If you look at the example intermediate joints in the descriptor for 20605 they include: temporomandibular, acromioclavicular, wrist, elbow or ankle, or olecranon bursa. The example large joints listed for code 20610 include: shoulder, hip, knee, subacromial bursa. If the physician performs the AC injection utilizing ultrasound guidance with permanent recording and reporting, then you should report code 20606 instead of 20605. And don’t forget to bill the HCPCS II code for the medication itself.

*This response is based on the best information available as of 10/27/16.

CPT Coding for Converting to an Open approach

Question:

My doctor started a laparoscopic cholecystectomy that had to be converted to open due to significant adhesions. He documented both approaches and the laparoscopic approach took significant time before he had to convert to open. Can both be billed?

Answer:

Unfortunately, no. Whenever a “closed” procedure (laparoscopic, arthroscopic, endovascular) is converted to an open procedure only the open procedure may be reported. If a significant amount of time was spent attempting the closed procedure, and this is documented, a 22 modifier for increased procedural services may be appended to the open code. Don’t forget to add the appropriate diagnostic code to indicate the conversion. See the appropriate diagnosis codes below.

• Z53.31 Laparoscopic procedure converted to open

• Z53.32 Thoracoscopic procedure converted to open

• Z53.33 Arthroscopic procedure converted to open

• Z53.39 Other specific procedure converted to open

*This response is based on the best information available as of 10/27/16.

Reimbursement: Assistant Surgeon

Question:

What is the reimbursement for an assistant surgeon using modifier 80? Is the payment different for the primary and the assistant? What about a PA or nurse practitioner who assists at surgery?

Answer:

An assistant surgeon is described as one surgeon, of the same or a different specialty, providing assistance during a surgical procedure or CPT code.

Modifier 80 (modifier 82 for an assistant surgeon in an academic setting when a qualified resident is not available) is appended to any CPT code the assistant participates in. Medicare reimburses 16% of the allowable for the assistant surgeon (modifier 80 or 82) and multiple procedure/bilateral procedure reductions also apply. The primary surgeon’s reimbursement is not affected. In an assistant surgeon scenario, the assistant need not and should not dictate a separate note. However, it is critical that the primary surgeon document in his/her note, specifically what the assistant did. Stating an assistant was needed because the case was complex is not sufficient. The primary surgeon must state what the assistant did, for example, assisting with positioning and retraction, surgical closure, etc. When a physician assistant or nurse practitioner assists in surgery, Medicare reduces their reimbursement by 15% of what a physician would be paid for assisting, and Medicare directs us to designate a PA or NP service using modifier AS (instead of modifier 80).

Keep in mind, Medicare does not allow payment for assistant support for all surgical CPT codes. For private payers, coding guidelines and payment rates may vary.

*This response is based on the best information available as of 09/29/16.

Diagnosis Code for Laryngopharyngeal Reflux

Question:

I’m getting used to ICD-10-CM! Thanks so much for teaching me about it. I do have a question though. I can’t seem to find a diagnosis code for laryngopharyngeal reflux. What do you suggest?

Answer:

Actually, we’ve always suggested using K21.9, Gastro-esophageal reflux disease without esophagitis. Coincidentally, in a recent issue (first quarter 2016) of the American Hospital Association’sThe Coding Clinic, the same advice was provided.

*This response is based on the best information available as of 09/15/16.

Billing for Bravo Placement

Question:

How do I bill for the Bravo placement? I’m coding an EGD with 43235 and the Bravo code, 91035 but getting denied.

Answer:

Great question and one that came up at a recent ACS coding course! First, if endoscopy is performed to evaluate the underlying problem, this is coded as a diagnostic EGD endoscopy, 43235. If something therapeutic is performed during the endoscopy, for example a biopsy, the appropriate therapeutic endoscopy code would be reported. The Bravo capsule code, 91035 Esophagus, gastroesophageal reflux test with mucosal attached pH electrode placement, recording, analysis and interpretation, should be reported and the date Bravo capsule is removed a few days after placement. Also, if an EGD for diagnostic or therapeutic purposes was done previously and already diagnosed the problem, it would not be appropriate to report it with a subsequent Bravo placement.

*This response is based on the best information available as of 09/01/16.