Separate Procedure Billing

Question:

I am new to coding and have a Question:. I remember studying about “separate procedures” and have my first operative note that includes a code that has this in the code definition. The surgeon performed a diagnostic arthroscopy (CPT code 29870) and confirmed the meniscal tear prior to proceeding with the planned meniscectomy and chondroplasty.

Does this separate procedure mean we can bill it in addition the meniscectomy CPT code, or it is included?

Answer:

Thanks for your Question:. CPT code 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) is as you say a ‘separate procedure’ designated code. In your scenario, this means that the diagnostic arthroscopy is inclusive to the meniscectomy performed on the same knee during the same operative session and is not separately reportable. If the surgeon had performed a left knee meniscectomy and a right knee diagnostic arthroscopy, both services would be reportable with RT and LT modifiers to differentiate them.

*This response is based on the best information available as of 04/29/21.

Coding an Epidermal Inclusion Cyst

Question:

I excised an EIC lesion on the chest.  I coded this as D48.5 but my coder says this is the wrong diagnosis code.  What is the correct diagnosis code?

Answer:

ICD-10-CM code D48.5 (Neoplasm of uncertain behavior of skin) is incorrect as you have stated the patient has an EIC (epidermal inclusion cyst). You should report L72.0,(Epidermal cyst).

*This response is based on the best information available as of 4/1/21.

Number of Units for ADM Code (+15777)

Question:

I use two ADMs on each breast during a tissue expander reconstruction. Can I bill +15777 x 4 units?

Answer:

No, you’ll use the code +15777 once for each breast

Question:

I’m confused on whether to bill +15777 twice (once on each side) or with modifier 50. Please advise.

Answer:

Good question and we completely understand the confusion. CPT says not to use modifier 50 – rather, you’ll report +15777 x 2 units for bilateral procedures. However, Medicare’s Medically Unlikely Edits allow only 1 unit of +15777 to be paid per day. Therefore, for Medicare (and payors who follow Medicare guidelines), you’ll report +15777 with modifier 50 for bilateral procedures.

*This response is based on the best information available as of 04/01/21.

Medication Documentation

Question:

We are switching to a new EHR system. We have not always had great compliance with our providers documenting what we feel needs to be documented so we want to do it right. Are you able to advise what should be included in the medical record when the provider administers medications, for example intra-articularly?

Answer:

Thank you for your Question:. Like you, we find in audits that providers do not always include the basic information required to select and submit a HCPCS code for medications. In Orthopaedics, this is most commonly related to injections to tendons, nerves, joints to name a few anatomic locations.

Documentation should include the medication name, dosage (mg or mg/ml), the route of administration and location (e.g. flexor tendon sheath, tendon insertion site, left shoulder subacromial space). In Orthopaedics, for example, J3301 describes Triamcinolone Acetonide, 10 Mg/ml. Vials for this medication commonly are available in 40 mg/ml or 80 mg/ml vial concentrations. If the physician states that “2ml” was injected into the right knee joint, it is not known if 80 mg or 160 mg was injected without the concentration. The impact, other than recording the incorrect dose, may result in incorrect reporting of the J code. 1 milliliter of Triamcinolone 40 mg/ml is reported as J3301 x 4 units; 1 ml of Triamcinolone 80 mg/ml is reported as J3301 x 8. In the example of “2ml”, the variance would be J3301 x 8 versus J3301 x 16.

Also include documentation of patient tolerance or reactions to the medications and instructions for follow-up monitoring. Don’t forget to record include wastage of drugs as appropriate and instructed by the payor, using modifier JW.

*This response is based on the best information available as of 03/18/21.

Oncoplastic Reconstruction

Question:

I just realized CPT 19366 was deleted in 2021. Now what code do I use for an oncoplastic reconstruction?

Answer:

You’re right – CPT 19366 (Breast reconstruction with other technique) was deleted this year. You will code for whatever procedure you end up doing such as an adjacent tissue transfer (e.g., 14xxx), breast reduction (19318), or mastopexy (19316).

*This response is based on the best information available as of 03/18/21.

Procedure with Spine Surgeon

Question:

I was asked, by a new spine surgeon in town, to do the cervical approach for an anterior cervical decompression and fusion.  Do I use a regular neck dissection code such as 38724?

Answer:

Oh no, 38724 is for a modified radical neck dissection requiring removal of lymph nodes.  The cervical approach is actually included in the spine surgeon’s ACDF code.  This means you’ll both bill the same code, probably 22551, with modifier 62 (two surgeons or co-surgery).  Use +22552-62 for each additional level for which you do the cervical approach.

*This response is based on the best information available as of 03/04/21.