Postoperative Incision Drainage

Question:

A patient had bilateral breast augmentation 5 weeks ago. She developed some drainage out of the lateral aspect of her left breast inframammary incision. The area was probed in the office with a Q-tip and it communicated with the implant pocket so I did a wash out of the left breast and replacement of the implant. We are charging the patient, not the insurance company, and my coder wants to use 19328 for the implant removal, 10060 for the washout, and 19325 for the new implant placement to determine our fee. I think my coder is unbundling and I should only charge my fee for 19325. What are your thoughts?

Answer:

I agree with you to use only 19325 for your fee comparison. The removal (19328) is included in the new placement (19325) because you couldn’t put a new implant in unless the old one was removed. Also, the wound washout would not be separately reported.

*This response is based on the best information available as of 10/31/19.

Thyroidectomy and Parathyroidectomy

Question:

Can we charge a thyroidectomy (e.g., 60240) when we do a parathyroidectomy (60500)

Answer:

Yes, but only if there is different pathology to support 60500.  The CPT Assistant from December 2012 states the following:

When a thyroidectomy is performed for malignancy, the parathyroid glands may also be removed, and because this would be considered incidental, the parathyroidectomy (60500) would not be separately reported. For example, if a left thyroidectomy was incidental to a left parathyroid biopsy and resection, then the work is considered inclusive of the parathyroid gland removal described by code 60500, as this code refers to all four parathyroid glands and is not reported as a unilateral procedure. Therefore, only code 60500 would be reported. However, if the thyroid lobectomy was performed for an independent diagnosis, then code 60220 would also be reported with modifier 59, Distinct Procedural Service, appended.

*This response is based on the best information available as of 10/31/19.

Augmentation of Pedicle Screws

Question:

I injected cement into the pedicles to augment screws in a patient with osteoporosis. My coder suggested using +22859 (Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)) for this procedure but that didn’t seem right to me. What is your advice?

Answer:

We agree with you that +22859 is not accurate. Augmentation of pedicle screws is not separately reported as it is included in the posterior instrumentation code (e.g., +22840, +22842) when performed.

*This response is based on the best information available as of 10/31/19.

E/M and Fracture Manipulation

Question:

We have joined a new health system and the coding staff members (new to orthopaedics) are removing all E/M-57 services when reported with a fracture manipulation code. The coding staff members are stating these are inclusive to the fracture, as the physician has to evaluate the patient to determine if the fracture needs manipulation. After many conversations, they agreed to hear from others on whether or not the E/M is separately reportable.

Answer:

Congratulations to your team for working with and educating the new coding team to the world of orthopaedics.

If the documentation supports the E/M service, it is reportable when assessing a fracture that resultantly requires manipulation.

The patient may present with a known fracture (or not). The physician must evaluate the patient to determine the nature of the injury. X-rays are typically ordered and interpreted, or reviewed if taken at an outside facility. The physician diagnoses the fracture as displaced requiring manipulation, whether it will be treated with closed or open reduction. The E/M service associated with evaluating a patient with a fracture is not included in global fracture care.

Append modifier 57 to the E/M CPT code if the treatment of the fracture is performed on the same day or the day following the E/M service.Note, although CPT rules call for using modifier 57 when you are protecting an E/M service performed for a procedure with a 90 day global period, some payors may instead require modifier 25 when the fracture treatment does not require taking the patient to the OR.

*This response is based on the best information available as of 10/17/19.

Providing the exposure for a neurosurgeon. How is it coded?

Question:

A neurosurgeon asked my vascular surgeon to perform the exposure for an anterior spine procedure.  Does he report an exploratory lap his work?

Answer:

No. providing the exposure for a neurosurgeon for an anterior spine  procedure is co-surgery, since code 22558,Arthrodesis, anterior interbody techniqueincludes both the exposure/approach and the work on the spine.  Both surgeons append the co-surgery modifier 62 to code 22558.

*This response is based on the best information available as of 10/17/19.

Removal of Breast Implant with Capsulectomy

Question:

My doctor specializes in breast reconstruction and has been asking me to bill 19328 (removal of intact breast implant) along with 19371 (capsulectomy) when he has to do a capsulectomy and remove the implant. It has come to my attention that this may be wrong and that 19328 is included in 19371. The CPT book is unclear and there is not a National Correct Coding Initiative (NCCI) edit between these two codes. So can I bill both?

Answer:

This is great example of where Medicare’s NCCI edits don’t reflect accurate coding. A CPT Assistant newsletter states “A capsulectomy (CPT code 19371) involves removal of the capsule. The implant is also removed and may or may not be replaced.” Therefore, CPT 19370 (capsulotomy) is included in 19328 when performed to remove the implant. CPT 19371 (capsulectomy) includes 19328 so both codes would never be reported for the same breast.

*This response is based on the best information available as of 10/17/19.