Primary Difference in Lumbar Laminectomy Codes

Question:

What is the primary difference between lumbar laminectomy CPT codes 63030 and 63047?

Answer:

The primary difference in use of these CPT codes is the diagnosis; CPT code 63030 is for removal of a disc due to herniation or degenerative disc disease and CPT code 63047 is for decompression of the nerve due to stenosis or spondylosis.

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

Chronic Pain Management G Codes

Question:

I'm struggling to understand the guidelines for HCPCS code G3002 and G3003. Is there any guidance you could provide?

Answer:

CMS's MLN006764 September 2024 provides guidance on the appropriate use of Chronic Pain Management (CPM) HCPCS codes G3002 and G3003. Medicare defines chronic pain as “persistent, or current pain lasting longer than three months.”

The HCPCS codes are used for reporting "chronic pain management” and treatment monthly bundle including:

• Diagnosis

• Assessment and monitoring diagnosis

• Administration of a validated pain rating scale or tool

• Development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes;

• Overall treatment management; facilitation and coordination of any necessary behavioral health treatment;

• Medication management;

• Pain and health literacy counseling;

• Any necessary chronic pain related crisis care;

• Ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate.

Criteria and documentation requirements

The initial visit must be face-to-face visit for at least 30 minutes provided by a physician or other qualified health professional. 30 minutes must be met or exceeded to bill for G3002.

G3003 can be added for each additional 15 minutes of chronic pain management and treatment personally provided by a physician or other qualified health care professional, per calendar month. The entire 15 minutes must be utilized in to report.

You must develop and maintain a person-centered plan.

You must provide and document the elements listed in the code bundle to the first month for each patient. Subsequent months do not require all listed components.

Although this code was created by CMS, we recommend you reach out to your commercial payors as they may reimburse for them as well.

G3002 is billed once per calendar month. G3003 is billable for as many times as medically necessary within the calendar month and calculated in 15-minute increments.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

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

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.