Exploration of Fusion (22830) – Two Questions Answered

Question:

Can we bill 22830 with modifier 50 because we explored both sides?

Question:

Can we bill 22830 for each level explored?

Answer:

No and no. CPT 22830, for exploration of spinal fusion, is used once regardless of the number of levels explored. It is assumed that you explore “both sides” of the spine which is typically considered a central structure from a coding standpoint.

*This response is based on the best information available as of 04/13/17.

Registered Nurse FA (First Assistant) vs. a Formal Mid-Level Provider (PA, etc.) Billing Difference

Question:

Is there a difference in billing and especially reimbursement for a registered nurse FA (first assistant) vs. a formal mid-level provider (PA, etc.)?

Answer:

Yes, there is a difference in how these two types of practitioners can be billed and expected reimbursement.  The answer will be payor dependent.

Physician Assistants, Nurse Practitioners and Clinical Nurse SpecialistsMedicare credentials only Physician Assistants (PA), Nurse Practitioners (NP), and Clinical Nurse Specialists (CNS) as assistants at surgery for the purpose of orthopaedic surgery.  Assistant claims are reported in the PA, NP or CNS name with the AS appended.  Medicare, when payment is allowed, reimburses the practice at 13.6% of the surgeon’s allowable for the primary procedure. The appropriate multiple procedure payment formula is applied to the subsequent procedures on the same day.

Other payors may or may not follow Medicare rules.  Reimbursement and claim submission are based on contractual arrangements. Check individual payor rules for claim submission rules (e.g. modifier use, separate claim) and expected reimbursement.

RNFAsRNFAs are not credentialed by Medicare, so you would not bill or expected to be paid for their work by the MAC.

Other payor rules for RNFA coverage/reimbursement will vary, and would need to be researched directly with the health plans in your market.

*This response is based on the best information available as of 04/13/17.

Billing for Pre-Op H&P Visit

Question:

Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer:

No, the H&P in this case is not a billable visit.  This question comes up often and was addressed by AMA CPT Assistant in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional Question:s. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT says once the decision is made to proceed with surgery the subsequent visits related to the procedure (e.g., doing H&P, getting consent form signed, answering Question:s) are included.  However, in some cases a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease and asthma) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery.  This visit can be billed as an E&M visit as the decision for surgery is just now being made.

*This response is based on the best information available as of 04/13/17.

Endoscopic Transnasal Pituitary Tumor Removal

Question:

I’m confused.  Should I use 61548 vs 61580 & 61600 to bill an endoscopic transnasal approach to remove a pituitary tumor?  Or is this an unlisted code (64999)?

Answer:

Good question – there are actually 3 CPT codes that specifically address removal of a pituitary tumor none of which are the skull base surgery codes you asked about (61580 & 61600).  They are listed in the table below:

CPT Code	CPT Descriptor	Approach
61546	Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach	Craniotomy, open
61548	Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic	Transnasal or transseptal using a microscope
62165	Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach	Transnasal or trans-sphenoidal using an endoscope

The codes, 61580 and 61600, are skull base codes which require an open approach and are not used to report transnasal procedures.

So there is a code for the procedure you describe and that is 62165.  Remember to append modifier 62 (two surgeons) if the approach is performed by the otolaryngologist (both surgeons report 62165-62).

*This response is based on the best information available as of 03/30/17.

Advancement Flap

Question:

My physician excised a malignant skin lesion from the left cheek measuring 2.0 cm. The defect was repaired with a rotational advancement flap with total primary and secondary defect area of 4.75 sq cm. I submitted my claim with CPT 14040 (advancement flap), 12052-51 (repair), and 11642-51 (malignant lesion excision). My claim was denied. Did I code this correctly?

Answer:

You should have reported one CPT code 14040 for the advancement flap which includes the lesion excision and repair. You should resubmit the claim with CPT 14040 and you should get paid.

*This response is based on the best information available as of 03/16/17.

Denials of 20930 and 20936

Question:

I’m new to neurosurgery coding and notice a big problem with denials. Medicare doesn’t pay us on 20930 and 20936. I’ve been appealing but don’t seem to have any success. Can you help?

Answer:

While CPT says it is accurate to code 20930 (morselized allograft) and 20936 (local autograft), Medicare considers both codes “bundled” into the primary code which is typically an arthrodesis/fusion code. Accept these denials and don’t waste your time appealing denials to Medicare.

*This response is based on the best information available as of 03/16/17.