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Cancer Surveillance E/M
My physician saw an established patient for follow-up in the office for cancer surveillance. The patient is doing well and no treatment is indicated. In addition, the physician removes a benign lesion on the right anterior neck (1.1 cm) and the patient is being treated for a rash that is acute. The physician recommends cleansers and moisturizers and prescribes a topical steroid. What codes should be billed?
Question:
My physician saw an established patient for follow-up in the office for cancer surveillance. The patient is doing well and no treatment is indicated. In addition, the physician removes a benign lesion on the right anterior neck (1.1 cm) and the patient is being treated for a rash that is acute. The physician recommends cleansers and moisturizers and prescribes a topical steroid. What codes should be billed?
Answer:
An E/M is supported for cancer surveillance and treating the rash. The problems addressed are low complexity (1 acute uncomplicated and 1 stable chronic) with moderate risk (prescription drug management). The level supported is 99213-25. CPT code 11422 is reported for the benign lesion excision on the right anterior neck.
*This response is based on the best information available as of 7/03/25.
Muscle Flap Denial
We received a denial for a muscle flap. We appealed, and unfortunately, the denial was upheld due to the documentation. Can KZA provide some insight?
Question:
We received a denial for a muscle flap. We appealed, and unfortunately, the denial was upheld due to the documentation. Can KZA provide some insight?
Answer:
Thank you for your inquiry.
The operative note was not included in this inquiry. Documentation should support flap elevation, identification, and preservation of the blood supply (naming the pedicle/ identifying the vein and artery), transfer and inset of the flap, and donor site closure.
Documenting the details is essential – these codes are being scrutinized more closely!
*This response is based on the best information available as of 7/03/25.
Free Nipple Grafts with Breast Reduction
In the setting of breast reduction, when free nipple grafts are done, is this separately reportable?
Question:
In the setting of breast reduction, when free nipple grafts are done, is this separately reportable?
Answer:
No – it would not be appropriate to report CPT 15200 for the harvest of the nipple areola complex for free graft. This work is considered included in CPT 19318 for breast reduction and therefore not separately reportable.
For the scenario as described, the appropriate CPT to report is only 19318.
*This response is based on the best information available as of 6/19/25.
Erector Spinal Block with Discectomy
Our surgeon states in the procedure title “Fluoroscopic Erector Spinae Block (ESP) L5”. The documentation supports this as performed bilaterally at L5 prior to the surgical incision. Is this separately reportable?
Question:
Our surgeon states in the procedure title “Fluoroscopic Erector Spinae Block (ESP) L5”. The documentation supports this as performed bilaterally at L5 prior to the surgical incision. Is this separately reportable?
Answer:
Thank you for your inquiry. It appears you have good documentation; however, this block is inclusive of the surgical procedure when performed by the operating surgeon. The timing of this (pre-incision) and fluoroscopically vs post discectomy, does not change the injection as being inclusive.
*This response is based on the best information available as of 6/19/25.
Ablation of Thyroid Nodules
My physician performed a percutaneous radiofrequency ablation of 3 thyroid nodules, one in the lower part of the left lobe and 2 in the right lobe. I am not sure what CPT code I should report. Can you help?
Question:
My physician performed a percutaneous radiofrequency ablation of 3 thyroid nodules, one in the lower part of the left lobe and 2 in the right lobe. I am not sure what CPT code I should report. Can you help?
Answer:
Certainly. There are 2 new CPT codes to report percutaneous radiofrequency ablation of thyroid nodules: CPT code 60660 (Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, including imaging guidance, radiofrequency) and CPT code 60661, an add-on code for the additional lobe. In this instance, you will report 60660 for the left lobe and 60661 for the right lobe. Keep in mind that imaging guidance is included and should not be reported separately.
*This response is based on the best information available as of 6/19/25.
Aquaphor and UVB Billing
Some of our dermatology physicians use Aquaphor as a conductive agent when doing UVB for our psoriasis patients and billing CPT code 96910. We see that Aquaphor is not considered a conductive agent, but we wanted to get your feedback to make sure. Should we use CPT code 96910 or 96912?
Question:
Some of our dermatology physicians use Aquaphor as a conductive agent when doing UVB for our psoriasis patients and billing CPT code 96910. We see that Aquaphor is not considered a conductive agent, but we wanted to get your feedback to make sure. Should we use CPT code 96910 or 96912?
Answer:
First, Aquaphor is not a conductive agent. It is very clear from the CPT guidance that 96910 (photochemotherapy) is reported with tar and ultraviolet B rays (Goeckerman treatment) or petrolatum and ultraviolet B rays. If you use Psolarens, the correct code to report is 96912. If other substances or no substance is used, you report 96900 (Actinotherapy (ultraviolet light)). Aquaphor would fall into that category.
*This response is based on the best information available as of 6/19/25.
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