Skin Tag Removal

Question:

One of the doctors removed 4 skin tags by shave, so she wants to code them as shaves of epidermal lesion codes 11300-11313.  Is that correct?

Answer:

No. The skin tag removal codes 11200-11201 should be reported as they are diagnosis-code specific.  The method of removal is not the driver for the code choice.  CPT guidance on the codes state that removal of skin tags “include scissoring orany sharp method, ….” which would include shave.

*This response is based on the best information available as of 1/31/19.

Ultrasound Guidance with a Carpal Tunnel Injection

Question:

When performing a carpal tunnel injection (20526) using ultrasound, what do I need to document to support reporting 76942?

Answer:

In order to report ultrasonic guidance using CPT code 76942 a permanent image of the ultrasound must be maintained.  It is recommended that you document the imaging guidance in a separate paragraph in the procedure note. Don’t forget medication (J code) can be reported separately for the injection.

*This response is based on the best information available as of 1/31/19.

Diagnosis Code for Post Op Visits

Question:

What’s the best way to do the diagnosis coding for postop visits? I mean, does it really matter since we aren’t billing for a visit?

Answer:

Yes, it is important to accurately code the diagnosis. The ICD-10-CM guidelines for postop/aftercare include the following:

1. If the original diagnosis is trauma (eg, using an S diagnosis code)ora code that requires a 7^thcharacter (eg, M80-): then you’ll continue to use the original diagnosis code but you’ll change the 7^thcharacter to one which includes “subsequent encounter”.  For example, a finger fracture – when you fixed the fracture in surgery you used a diagnosis code with a 7th character of, say, A (initial encounter, closed fracture).  So for your postop visits (CPT 99024), you’ll use the same finger fracture diagnosis code but with a 7^thcharacter of, say, D (subsequent encounter, routine healing).

2. For non-trauma diagnoses (and those that do not require a 7^thcharacter): Now you’ll switch to a Z code when you’re using CPT 99024.  Look at the Z48.- codes…there are several that can be used such as:

Z48.00   Encounter for change or removal of nonsurgical wound dressing

Z48.01   Encounter for change or removal of surgical wound dressing

Z48.02   Encounter for removal of sutures (or staples)

Z48.03   Encounter for removal of drains

*This response is based on the best information available as of 1/31/19.

Fem- Fem Bypass

Question:

How is a left femoral to right femoral artery bypass with PTFE reported?

Answer:

Report code 35661, Bypass graft, with other than vein, femoral- femoral. This code applies to fem-fem bypass in the same leg or from one leg to the opposite leg.

*This response is based on the best information available as of 1/17/19.

E/M on Same Day as an Injection

Question:

My pain management physician saw a patient in the office and the chief complaint states that the patient is here for a trigger point injection (20552).  He has documented a detailed history, expanded problem focused examination and the decision making is low complexity since the patient is established and the pain is worsening.  Can I bill 99213-25 and the trigger point 20553 together?

Answer:

In order to report an E/M service with Modifier 25 on the same day as another procedure or service the service must be separately identifiable and goes above and beyond the preoperative work for the injection, an E/M can be reported if the patient’s condition required a significant E/M service on the day a procedure or service identified by a CPT code was performed.

• Above and beyond other service provided
• Beyond the usual preoperative and postoperative care associated with the procedure that was performed
• Different diagnosis is not required

However, based on the reason for the visit, “patient here for trigger point injection”, and the intent of the visit is the injection, the E/M service is included in the preoperative workup and not reported separately. Keep in mind there is an Inherent E/M service in every procedure.

*This response is based on the best information available as of 12/13/18.

I&D in the Office during the Global Period

Question:

Our surgeon saw a patient in the office for a routine post-op check during the global period of an excision of a soft tissue tumor. During the visit the surgeon notes that the patient has some fullness and performs a superficial incision and drainage in the office. I have the correct CPT code, but I am wondering if I should use Modifier 58 or 79. I think the correct modifier is modifier 79 because he documents a new diagnosis “seroma”. Do you recommend modifier 58 or 79?

Answer:

The reporting (or not) of this service performed in the office during the global period will be payor dependent. If the payor is Medicare, or follows Medicare rules, the visit is not reportable as this a complication of the original surgery.

If the payor follows CPT rules, and the surgeon determines this is not “typical postoperative care” then traditionally no modifiers are appended. Modifier 79 is typically reserved for an ‘unrelated’ procedure/ service at a different location. The seroma is secondary to the surgical intervention—thus if there had not been surgery, there would not be a seroma.  Modifier 58 is incorrect as this is not a planned procedure, is not more extensive, and is not part of the treatment plan.  Survey your private payors to determine which modifier, if any, is required.

*This response is based on the best information available as of 12/13/18.