Evacuation of Cervical Epidural Hematoma

Question:

How do I code a cervical laminectomy with extradural epidural hematoma evacuation?  I was thinking about using 63265 but my co-worker said this code is for a tumor removal and not for a hematoma.

Answer:

Sorry, but your co-worker is incorrect.  The code series, 63265-63268, is for laminectomy procedures to remove intraspinal lesions “other than neoplasm” so these codes would never be used for tumor removal.

Examples of extradural non-neoplasm lesions where 63265-63268 are used include a hematoma or abscess.

*This response is based on the best information available as of 04/19/18.

Removal of Mandibular Implant

Question:

We are removing old plates from the right and left mandible. It is ok to use 20680 x 2?

Answer:

There was just a CPT Assistant about this in January 2018. CPT 20680 (Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)) may be reported twice for removal of implants from noncontiguous sites on the same bone, such as the mandible, if separate incisions are made.  However, use 20680 only once if one incision is made to remove bilateral implants from the same bone such as the maxilla.

*This response is based on the best information available as of 04/19/18.

Diagnostic Ultrasound and Ultrasound Guided Injections

Question:

Our sports medicine physicians are reporting diagnostic ultrasounds (76881) and ultrasound guided injections at the same session, same joint. We are receiving denials as inclusive and are not understanding why they are being denied.

Answer:

Thanks for your inquiry. The ultrasound guided injections (20604, 20606 and 20611) include ultrasound image guidance in the definition of the code.  These injections codes include the work associated with assessing the anatomic structures of the joint and the documentation of a separate report.   Trying to report CPT code 76881 (Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation)is inclusive to the work valued into the joint injection codes, hence the denial as inclusive.

This is also true of the use of ultrasound guidance with any other injection codes; the diagnostic component is inclusive to CPT code 76942 when this code may be reported with an appropriate injection code.

Medicare also considers the service to be inclusive..  The first reference is from the Medicare NCCI guidelines; the second notation is the introduction of new NCCI PTP edits effective April 1, 2018

Medicare NCCI guidelines also contain the following reference:

Section IX-H, Radiology Services – note: 2018 text revision highlighted in red

9. Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions.  For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement…) when performed in different anatomic regions on the same date of service.  Physician should not avoid edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.

Additionally, effective April 1, 2018 , CMS NCCI implemented PTP edits  between CPT codes 20604, 20606 and 20611 and 76881.  CPT code 76881 is now identified a Column 2 PTP edit.

*This response is based on the best information available as of 04/19/18.

Coding a Skin or Nipple Sparing Mastectomy

Question:

What is the appropriate code for a complete skin sparing or complete nipple sparing mastectomy?

Answer:

The code for a mastectomy described as complete skin sparing or complete nipple sparing mastectomy is 19303.

*This response is based on the best information available as of 04/19/18.

Coding for Paravertebral Blocks

Question:

What are the codes 64461-64463 used for?

Answer:

These codes are used to treat acute and chronic pain which includes thoracic pain after mastectomy or multiple rib fractures.  The block (paravertebral or paraspinous) targets the intercostal and spinal nerves and branches.  CPT 64461 is used for a single injection and 64462 is the add-on code for the second and any additional injection site.  Code 64463 is used for continuous infusion by catheter.  Imaging guidance is included and CPT code 64462 can only be reported once per day.

*This response is based on the best information available as of 03/29/18.

Right Colectomy and Small Bowel Resection

Question:

The surgeon did a right colectomy and also documented a resection of the ileum. Is this billed separately as a small bowel resection?

Answer:

No. The resection of the ileum and anastomosis of the new end of the ileum (the neoterminal ileum) to the remaining colon (an ileocolostomy) is included in the code; 44160 for open and 44205 if performed laparoscopically.

*This response is based on the best information available as of 03/29/18.