Inpatient Consultation Coding for Medicare

Question:

If you see a Medicare patient for the first time in the hospital as an inpatient consultation, what code would you bill for the EM?

Answer:

The EM would be reported as an Initial hospital or observational care codes (99221-99223) with the appropriate level based on MDM or Time. Medicare does not allow payment for inpatient consultation codes 99252-99255.

*This response is based on the best information available as of 3/27/25.

Cast Overwrapping

Question:

Can a practice report a CPT code for a cast application code if they only place a fiberglass overwrapping to current cast?

Answer:

The practice will report a supply code only if the old cast was not removed and replaced but only had additional wrapping placed.

An example may be the overwrapping of a previously applied bivalved cast. The practice would not report a new cast application code but may report the supply code.

*This response is based on the best information available as of 3/27/25.

Discrepancy between Procedure Title and Documentation Details

Question:

If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?

Answer:

CPT codes are always chosen based on the documentation within the detailed portion of an operative record. If the details within the body of the report do not match the “procedure title” listed in the beginning of the operative report, the provider should be queried for clarification and a possible addendum to the record if necessary.

*This response is based on the best information available as of 3/27/25.

Diagnosis Coding for Reconstruction Following Mastectomy

Question:

Our plastic coders are debating ICD-10 coding for reconstruction following a mastectomy. We want KZA to provide some guidance. Should we be reporting breast cancer (C50.-) as primary ICD-10?

Answer:

Thank you for your inquiry.

For breast reconstruction following mastectomy, often, three ICD-10 codes are assigned for this encounter. Let's explore and walk through this below.

• For the primary ICD-10, since the plastic surgeon is performing the reconstruction and not treating cancer with the mastectomy, it would be appropriate to report Z42.1 and not the malignant neoplasm of breast ICD-10.

• As a secondary ICD-10, the plastic surgeon would assign a code for the acquired absence of breast Z90.1- to reflect left, right, or bilateral acquired absence of breast.

• Depending on the timing of the reconstruction, a third ICD-10 of either a malignant neoplasm breast (C50.-) or a personal history of malignant neoplasm (Z85.3) are options to consider.  

  • If this is an immediate reconstruction, a malignant neoplasm of breast C50.- could be reported.

  • If this is delayed reconstruction and the patient has completed all cancer treatment, ICD-10 Z85.3 for a personal history of malignant neoplasm breast could be reported.

Remember - ICD-10 supports the medical necessity of the services and work performed, and documentation should support the ICD-10 codes reported.

*This response is based on the best information available as of 3/27/25.

Biopsy Following Mohs Surgery

Question:

I have received conflicting information and would appreciate clarification. I had a patient referred to me by a family physician for a possible basal cell carcinoma. The patient has never had a biopsy. I did a punch biopsy and the diagnostic frozen section which confirmed a morpheaform basal cell carcinoma and performed a stage 2 Mohs procedure 17311 and 17312. Can I bill for the biopsy even when I did the Mohs surgery on the same date?

Answer:

The answer to your question is yes, you can bill the punch biopsy (11105-59) and the frozen section (88331-59) in addition to Mohs surgery. If a biopsy has not been performed within the last 60 days prior to Mohs surgery, you can report the biopsy and frozen section. Make sure you append Modifier 59 to the biopsy and frozen section to identify that the procedure was distinct and separate.

*This response is based on the best information available as of 3/13/25.

Should the Acupuncturist be Present

Question:

When a patient receives acupuncture for 30 minutes, does there need to be personal one-on-one contact with the patient in addition to re-inserting the needles?

Answer:

CPT coding for acupuncture is based on the time spent actively performing the procedure. This includes selecting the acupuncture points, inserting the needles, monitoring the patient’s response, and making any necessary adjustments. All these tasks require direct interaction with the patient throughout the treatment session. Essentially, the billing code reflects the dedicated time the practitioner spends actively treating the patient, not just the needle insertion itself.

Therefore, yes, the acupuncturist must be present for the entire procedure.

*This response is based on the best information available as of 3/13/25.