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Facet Wedge?
Our surgeon used a facet wedge device at C1-C2 and then performed facet arthrodesis with instrumentation. How would I code the facet wedge?
Question:
Our surgeon used a facet wedge device at C1-C2 and then performed facet arthrodesis with instrumentation. How would I code the facet wedge?
Answer:
Thank you for contacting KZA with an inquiry!
The codes for posterior intrafacet implants (facet wedge/dowel arthrodesis) are Category III codes: 0219T (Cervical, 0220T (Thoracic), & 0221T (Lumbar). These codes include imaging and placement of bone grafts, synthetic devices, and arthrodesis.
Based on the presented scenario, if a facet fusion is performed and documented, it would not be appropriate to report 22600 instead of or in addition to 0219T. CPT provides a list of codes not to report in conjunction with at the same level. This is appropriately reported with 0219T.
*This response is based on the best information available as of 7/03/25.
Evaluation and Management Service on the Same Date as an Office Procedure
A patient came into the office for a balloon sinus ostia catheterization and dilation of the maxillary, sphenoid and frontal sinuses bilaterally. My surgery scheduler has already obtained pre-certification for the procedure as it is covered in the office setting. I performed an examination and then did the procedure. I then performed a sphenoid, frontal, and maxillary dilation bilaterally. Can I bill an E/M service since I examined the patient?
Question:
A patient came into the office for a balloon sinus ostia catheterization and dilation of the maxillary, sphenoid and frontal sinuses bilaterally. My surgery scheduler has already obtained pre-certification for the procedure as it is covered in the office setting. I performed an examination and then did the procedure. I then performed a sphenoid, frontal, and maxillary dilation bilaterally. Can I bill an E/M service since I examined the patient?
Answer:
No, since the focus of the visit was the procedure and you have already obtained precertification for the procedures on the sphenoid and frontal sinus dilation (CPT 31298-50) and the maxillary dilation (31295-50), the E/M service is inherent to the procedure and should not be reported separately. In this situation there is not a significant separate identifiable justification for an E/M service.
*This response is based on the best information available as of 7/03/25.
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.
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