Billing for a Simple Repair of the Scalp

Question:

My physician is billing a simple repair of the scalp with CPT code 12001 when he uses steri-strips to do the repair. I don’t believe this is correct. Can we report the use of steri-strips alone to report a simple repair?

Answer:

According to CPT guidelines, repairs are reported when the provider utilizes sutures, staples, or tissue adhesives either singly or in combination with each other, or in combination with adhesive strips. Repairs utilizing adhesive strips alone are not separately reportable. They are part of the E/M service.

*This response is based on the best information available as of 5/22/25.

Postoperative Pain Block by Surgeon

Question:

This question may fall outside the interventional pain questions typically submitted to KZA.

Our surgeon is performing a total knee replacement and a postoperative pain block on a Medicare patient. Can we report the block in addition to the total knee arthroplasty procedure?

Answer:

Thank you for your submitted question!

Both CPT and CMS consider postoperative pain management by the physician performing the surgical procedure to be included in the global surgical package and not separately reportable.

Based on the submitted scenario, the surgeon's appropriate coding is 27447 for the total knee arthroplasty.

*This response is based on the best information available as of 5/22/25.

Risk of Patient Management

Question:

Our new surgeon wants to code a level five encounter for all patients where the patient is scheduled for inpatient surgery. He states he was educated that all outpatient surgeries are automatically a level four encounter, and all inpatient surgeries are automatically level five encounters. Have we been assigning the level of risk incorrectly?

Answer:

Unfortunately, it sounds as though the surgeon received incorrect information.

The risk of patient management (one of three MDM Elements) is based on the procedure risks and patient specific risks for the surgical procedure. Whether the surgery is inpatient or outpatient is not a factor in determining the risk level for the encounter.

Let’s look at CPT’s MDM table under “Risk of complications and/or morbidity or mortality of patient management as a possible source of confusion.

CPT provides several examples for high risk:

· “Decision regarding hospitalization or escalation of hospital level care.”

· “Decision regarding elective major surgery with identified patient or procedure risk factors”

· “Decision regarding emergency major surgery”

If one of these criteria is met, then the provider reaches high risk as one of the elements of MDM. To bill the service as high risk, one of the two other elements (number and Complexity of problems addressed at the encounter or amount and/or complexity of data to be reviewed and analyzed) must also be at high.

This level of E/M service is associated with a presenting problem where the patient requires hospitalization for management of the presenting problem/condition and meets the MDM elements criteria not for surgery itself.

Thoracic Calcified Disc

Question:

The documentation indicates a costovertebral approach and rib removal to access and dissect a calcified thoracic disc at T9-T10. How if this coded? And can the rib removal be reported separately?

Answer:

This is most likely coded as 63064, Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment. The rib removal is included. A costotranversectomy for the rib removal, is included and not separately reported.

*This response is based on the best information available as of 5/22/25.

Septoplasty with a Nasal Swell Body Reduction

Question:

I performed a Septoplasty for a patient with a deviated nasal septum. During the procedure, I also performed a nasal swell body reduction on the septal mucosa. My coder told me I could report 30520 for the Septoplasty but I could not report the lesion excision with 30117. I don’t understand why I cannot report both codes together. Can you advise?

Answer:

Your coder is correct. According to CPT Assistant (6/19), it is not appropriate to report code 30117, excision or destruction (e.g., laser), intranasal lesion, internal approach, separately. The procedure described in code 30117 is included in code 30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, and should not be reported separately.

*This response is based on the best information available as of 5/22/25.

13160 in Addition to Tendon Repair?

Question:

We have a patient who sustained a laceration that was repaired in an emergency room. The patient now presents to our plastic hand surgeon to repair a lacerated tendon. The previously closed wound is opened, and the tendon repair is performed. Would it be appropriate to report 13160 in addition to the tendon repair CPT?

Answer:

No – an opening and closure are inherent in the tendon repair.

In this scenario, it would not be appropriate to report CPT 13160 in addition to the tendon repair – closure is inclusive.

*This response is based on the best information available as of 5/22/25.