Fluoroscopic Guidance and Trigger Point Injections

Question:

I would like to know if generally speaking if Medicare pays for trigger point injection CPT code 20552 with imaging guidance? If yes I would like to know if I can use fluoroscopy or it has to be ultrasound.

Answer:

Medicare as well as other payors should pay for fluoroscopy guidance separately unless they have a medical policy that differs from CPT Trigger point injections do not include imaging guidance and can be reported separately.From CPT Assistant: “The trigger point injection(s) codes (20552 and 20553) are reported once per session based on the number of muscles injected, regardless of the number of trigger points injected in each muscle. Code 20552 is reported for trigger point(s) injection(s) in 1 or 2 muscles, and code 20553 is reported for trigger points injection(s) in 3 or more muscles. If imaging guidance is utilized, report the appropriate radiology code (76942,77002, and 77021) in addition to the injection codes.”

*This response is based on the best information available as of 02/06/20.

Wound Vac Billing

Question:

I’m a general surgeon.  Some of my team are reporting the negative pressure wound therapy codes 97605 and 97606 when applying wound vacs after closing at the completion of their surgical cases.  As a result, I am told by my coders that billing for these wound vacs is not appropriate, since there is a Medicare NCCI edit that bundles this with more comprehensive procedures at the same anatomic area.

The physicians and coders disagree about how to handle these edits.  Some of the physicians believe the wound vacs are billable because they are applied to the skin which constitutes a different body system.  The coders think the wound vacs are dressings which are included in the global surgical fee and would not billable.  After multiple discussions with the physicians and coders, we are unable to provide a definitive answer.   Could I please ask you for your advice regarding this issue? What is the right answer?

Answer:

There are two layers to the issue; CPT rules and payor editing rules.

First, from a CPT perspective, the “wound vac” codes in the range of 97605-97608 are only reportable when placed at an open wound site.  For example, if a physician performed debridement of an open wound, did not close the wound, but placed a wound vac at the debridement site to promote healing, a code in the range 97605-97608 could be reportable if appropriately documented.   Additionally, in the case of delayed closure of the abdomen in damage control surgery, the placement of a wound vac over this open abdomen may be separately reported if documented correctly.

Codes 97605 and 97606 are used for placement of a non-disposable wound vac device, while codes 97607 and 97608 are used if the wound vac is disposable.    The codes are further differentiated by the wound size, either greater than 50 sq cm, or less than or equal to 50 sq cm.

If the wound site has been surgically closed, and a wound vac is placed over the closed wound site, then the use of the wound vac is not separately reportable, as it is being used as a dressing.

In the case of a “codeable” wound vac, payor rules that apply when other services are performed at the same time should also be considered.  For example, debridement code 11044 does not have an NCCI edit with code 97605, thus you should not have any issues reporting the two codes together.  Similarly, you should not find NCCI edits between the lower extremity decompressive fasciotomy codes and the wound vac codes – another type of procedure where it is not unusual to have delayed surgical closure of the wound site.

Damage control surgery, fasciotomy coding and use of wound vacs will be thoroughly covered in the ACS Successful Surgical Coding and Trauma and Intensive Care coding courses offered in several locations in 2021.

*This response is based on the best information available as of 02/06/20.

Ear Exam Under Anesthesia

Question:

Our surgeon performed an evaluation of the external ear canal on a pediatric patient, under general anesthesia, because the child would not allow the surgeon to evaluate the ears thoroughly in the office. We cannot find a CPT code for this service. Do we use an unlisted code?

Answer:

CPT code 92502, (Otolaryngologic examination under general anesthesia) describes a complete ENT exam under general anesthesia. If only the ears were examined, then modifier 52 (reduced services) would be appended to indicate an entire otolaryngologic examination was not performed.

*This response is based on the best information available as of 01/23/20

Keloid Scar Destruction

Question:

What CPT code should you report for laser removal of a keloid scar? What should be documented in the procedure note?

Answer:

You would report 17110. Documentation should always include:

Indications for proceduresRisks/BenefitsDocument location of lesion/keloid destroyedCM size of lesion before removal/destructionMethod of destructionDetail of the procedureAnesthesia/medications

*This response is based on the best information available as of 1/23/20.

Laceration and Fracture Repair

Question:

My physician is utilizing an open laceration on the patient’s chin for open reduction of a mandibular symphysis fracture and he wants to also charge for a complex laceration repair for that laceration. Is this billable or is it part of the ORIF code?

Answer:

If the fracture is repaired through the laceration then we code only the fracture repair – the laceration repair would not be separately reported.

*This response is based on the best information available as of 01/23/20.

Coding for Non-Biological Mesh Placement

Question:

How do I report placement of a mesh implant in the abdomen that is not a biological implant and not for an open incisional hernia?

Answer:

Placement of a non-biological implant in the abdomen is reported with code +0437TImplantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure).It is an intraoperative procedure that may be performed with an intra-abdominal surgery to lessen the risk of incisional hernia by adding mesh.

*This response is based on the best information available as of 1/23/20.