Pharyngectomy Code

Question:

Do I use CPT code 42950 when a limited pharyngectomy is done??

Answer:

No, you should report CPT code 42890 when a limited pharyngectomy is performed not CPT 42950 (Pharyngoplasty (plastic or reconstructive operation on pharynx).

*This response is based on the best information available as of 09/27/22.

2021 Evaluation and Management Codes: Is a History and Exam Required?

Question:

After a recent audit and review with my physicians, they are telling me that they do not need to document a history and/or exam any more for the new and established patients. That is not my understanding.

Answer:

You are wise to ask because that’s not exactly true; we hear it not infrequently. It is correct that the History or Exam will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that the physician/provider will document a “medically appropriate” (per CPT™) history and exam for each encounter.

In Orthopaedics, we find the History section to provide important information that assists with the Data Element sections in the MDM table. Items such as the location, duration of the problem, past treatments such as injections, documentation that external X-Rays were brought with the patient are helpful in determining the level of risk in addition to the remainder of the note.

Choosing a Modifier with a Colostomy Revision

Question:

What modifier is used to report a colostomy revision during the global period of the stoma creation?

Answer:

A modifier 78, return to the OR for a related procedure, in this case a complication of the creation, would be appended.

*This response is based on the best information available as of 09/22/22.

Coding a Decompressive Craniectomy

Question:

In a recent head trauma case, a decompressive craniectomy was performed with a partial temporal lobectomy, due to extensive damage. A hematoma was also evacuated. can we bill for the 61323 decompressive craniectomy code with lobectomy since only a partial lobectomy was done? And what about cooing for the hematoma evacuation?

Answer:

For the procedure described, code 61323, decompressive craniectomy with lobectomy, may be reported, even with a partial lobectomy.  The hematoma evacuation is included in code 61323.

*This response is based on the best information available as of 09/22/22.

New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is that the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.

Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three -year period.

In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

Changing Group Practices
What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?
If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:
The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in the Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period instead, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.

Billing Multiple Units

Question:

When billing 4 units of 11620 (4 charges with 1unit a piece with 76 modifier) to a Medicare Advantage plans we are getting denied for MUE stating that 3 units can only be reimbursed on the same date. Will changing the modifier to 59 bypass this edit or is it Medicare’s policy limit.

Answer:

An MUE of 3 is the maximum number of units you can report for a single beneficiary on a single date of service for the procedure. It would be inappropriate to bill the service with 4 units with Modifier 59.

*This response is based on the best information available as of 09/22/22.