Paramedian Forehead Flap on Previous Mohs Surgery

Question:

My doctor did a division and inset of a paramedian forehead flap on a patient that had Mohs surgery on their nose. Do I code 15620 since the flap was brought from the forehead, or 15630 since the flap was placed on the nose?

Answer:

Good Question:.  If you look at the code descriptors, they state, “Delay of flap or sectioning of flapat…”  This means that the code is chosen for where the flap is inset.  In your case, the flap was inset at the nose.  CPT code 15630 for division and inset at the eyelids,nose, ears, or lips, would be the correct code to report.  Don’t forget also that if repair of the donor site requires skin graft or local flap to repair, it is separately reportable.  Hope this helps.

*This response is based on the best information available as of 07/27/17.

Moderate sedation Denials. How do we get paid for 99153?

Question:

We are billing the new moderate sedation codes, but are getting denied on the second 15 minutes, 99153.  Almost all our patients have sedation for more than 15 minutes. What are we doing wrong?

Answer:

You are doing nothing wrong!  The codes you are referencing are listed below.  Code 99151 or 99152 are paid without a problem.  It’s code 99153 that is the issue. When Medicare valued these new codes as part of the Medicare Physician Fee Schedule, 99152 (or G0500 for GI endoscopy procedures) had an RVU assigned.  Code 99153, for the second 15 minutes, (or a minimum of 23 minutes total of sedation) did not have a professional fee value assigned, indicating that Medicare will not pay for these additional minutes. Medicare considers all physician work for moderate sedation to be covered by the single code; 99151 (or G0500 for GI endoscopy procedures). Continue to bill per CPT guidelines that allow this second code. Private payors may pay for this code. Write off the Medicare denial.

CPT Code	Description
?99151	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient younger than 5 years of age
?99152	initial 15 minutes of intra-service time, patient age 5 years or older
+99153	each additional 15 minutes intra-service time (List separately in addition to code for primary service)
G0500	Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older. Report additional time with 99153 as appropriate Use only for GI endoscopy procedures for Medicare patients

*This response is based on the best information available as of 07/27/17.

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 07/13/17.

Denials – Chemodenervation of the Facial Nerves for Migraine

Question:

We are getting denials for code 64615 chemodenervation of the facial nerves for migraine headache. Any suggestions?

Answer:

Code 64615 is reported for chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal, and accessory nerves, bilateral (e.g., for chronic migraine). Per CPT, code 64615 is used to report a chemodenervation injection procedure specifically for the treatment of chronic migraine. To report this code, the following criteria must be met:

• 15 or more days of headache or a headache that lasts 4 hours or more per day, prior to treatment.

• Treatment must include, 31 injection sites over 7 muscle groups are typically identified on the face, head, neck and upper back (the frontalis, corrugatore, procerus, occipatlis, temporalis, trapezius, and cervical paraspinal muscle groups). The code is reported once, for injection of these sites. Ultrasound guidance may be reported with these codes using 76942.

If this procedure is performed and reported accurately (as described above), appeal the denial with appropriate documentation.

*This response is based on the best information available as of 06/22/17.

Report actinic keratosis and seborrheic keratosis with 17000-17004 codes?

Question:

If a patient presents to the office with both AKs and SKs. The doctor destroys 11 AKs and 5 SKs. Are these all reported with 17000-17004 codes?

Answer:

No. The actinic keratosis (AKs) are considered premalignant and are reported using codes 17000-17004. The seborrheic keratosis (SKs) are considered benign and are reported using codes 17110-17111. In your case, the following codes should be reported:

17110 Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions

17000-59 Destruction premalignant lesions; first lesion

17003 X 10 Destruction premalignant lesions; second through 14 lesions, each

Make sure that you pay attention to the quantities in the code descriptors so that the proper units are billed. There is a CCI edit between 17110 and 17000 so modifier 59 (or XS) would need to be appended to 17000 to ensure proper adjudication. Hope this helps.

*This response is based on the best information available as of 06/22/17.

Multiple Fractures: One code or multiple?

Question:

Our new hand surgeon evaluated a patient with a base of the fifth metacarpal fracture and distal radius fracture. Both fractures were non displaced and the hand surgeon applied a short arm cast.   The hand surgeon submitted two CPT codes, one for the metacarpal fracture and one for the distal radius fracture.  We told the surgeon that only one CPT code may be reported because a single cast was applied.  The surgeon is in total disagreement and asked we reach out to KZA. Who is right?

Answer:

Thanks for your confidence in KZA to answer your coding dilemmas!  The answer is “It depends” on payor rules.

The surgeon is correct according to CPT rules.  Each fracture that is evaluated and treated and meets a global fracture code is reportable assuming unbundling is not occurring. In the scenario presented, there is no overlap between the two anatomic fractures and both global fractures codes, for example, 25600 and 26600 (assuming these codes define the fracture) are reportable.

But wait….

You may be correct if the payor is Medicare and hence the confusion sets in.   The Center for Medicare and Medicaid Services (CMS) via the National Correct Coding Initiatives (NCCI) published Medicare payment rules forPart B Medicare.  In your scenario,  the NCCI edits state, “If multiple dislocations and/or fractures are treated without manipulation and stabilized with a single cast, strapping, or splint, only one CPT code for closed dislocation or fracture treatment (without manipulation) may be reported.”

Your answer is correct if the payor is Medicare; the surgeons’ answer is correct if the payor follows CPT rules.   To ensure accurate reporting, report the surgical CPT codes according to the AMA CPT rules; apply payor rules appropriately based (e.g., Medicare NCCI payment rules are applied for Medicare Part B beneficiaries; private payor rules will vary based on contractual agreements).

Dr. Hand reports two CPT codes to non-Medicare patients for the non-manipulative treatment of the metacarpal and distal radius fractures.

Dr. Hand reports one CPT code if this patient was Granny, who has Medicare Part B coverage.

*This response is based on the best information available as of 06/08/17.