Hernia Repair and Small Bowel Resection

Question:

A patient with open repair of an incarcerated hernia is noted to have necrotic bowel within the incarcerated hernia. This area of non-viable small bowel is resected and anastomosis is performed. Is this separately billable?

Answer:

Yes, if another organ is involved in the incarcerated hernia, and needs to be resected or repaired, this may be maybe separately reported with the appropriate hernia repair.

*This response is based on the best information available as of 7/31/25.

DRIL Procedure

Question:

The surgeon said he did a DRIL procedure on an AC fistula. I’m not sure how to code this. Is it an unlisted code?

Answer:

The DRIL procedure (Distal Revascularization with Interval Ligation) is a surgical intervention to treat complications related to hemodialysis access. It is performed to address complications arising from hemodialysis access, such as ischemia (reduced blood flow) or steal syndrome (where blood flow is diverted away from the limb) in the affected extremity. It involves restoring blood flow to a limb while also addressing issues like high flow or steal syndrome by ligating (tying off) a portion of the access. This procedure aims to reduce pain, improve tissue viability, and prevent further complications in the affected limb. This procedure has an existing CPT code and is reported as 36838. 

*This response is based on the best information available as of 7/31/25.

Sacroiliac Joint Injections (SI Joint)

Question:

We are receiving denials from NGS Medicare for CPT code 20552 when we do SI joint injections using ultrasound guidance. Our typical diagnosis is sacroiliac dysfunction.

Does KZA have an insight into what may be causing the denial?

Answer:

Thank you for your inquiry.

You are correct that CPT code 20552 is appropriate for SI joint injections performed with ultrasound, following AMA CPT guidance. However, some Medicare Contractors and private payors are denying this code when used for the SI joint injection.

Without access to specific notes, Explanation of Benefits (EOB), or details about the specific MAC, the issue may stem from the following limitations listed in the LCD:

Trigger Point Limitations Excerpt: LCD 39662 Trigger Point Injections

• #4. Trigger points injections for treatment of headache, neck pain or low back pain in absence of actual trigger points, diffuse muscle pain, a chronic pain syndrome, lumbosacral canal stenosis, fibromyalgia, non-malignant multifocal musculoskeletal pain, complex regional pain syndrome, sexual dysfunction/ pelvic pain, whiplash, neuropathic pain, and hemiplegic shoulder pain are considered investigational and therefore are not considered medically reasonable and necessary.

• #5. Use of fluoroscopy or MRI guidance for performance of TPI is not considered reasonable and necessary.

• #6. The use of ultrasound guidance for the performance of TPI is considered investigational.

  • Limitation #6 specifically identifies "ultrasound guidance" as investigational, which could partially account for the denial.

Additionally, the NGS Medicare Billing and Coding Article (A59847) specifies the covered "sacral" diagnoses as follows:

• M48.00 - M48.08 Spinal stenosis, site unspecified - Spinal stenosis, sacral and sacrococcygeal region

It is important to note that sacroiliac dysfunction is not listed as a covered diagnosis under this article.

Sacroiliac dysfunction is not identified as a covered diagnosis.

Sources:

Billing and Coding: Trigger Point Injections (TPI), A45897

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=59487&ver=8

Trigger Point Injections (TPI), L39622

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39662&ver=5

*This response is based on the best information available as of 7/31/25.

63266 & 63267 - Reported Together?

Question:

If the provider removed an epidural abscess from T4-T9 via one incision and then did a separate incision at L4-5, can I bill CPT 63266 and 63267?

Answer:

Thank you for asking KZA!

Remember, the laminectomy for non-neoplasm code set (6326x and 6327x) are regional codes, meaning they include any number of contiguous laminectomies.

The key in the scenario is that these laminectomies were performed via two separate incisions; additionally, they are non-contiguous (T4-T9 and L4/L5). Yes, both codes (63266 & 63267) may be reported as described by the scenario in this inquiry.

*This response is based on the best information available as of 7/31/25.

27134 vs. 27137

Question:

What is the correct way to bill for a hip arthroplasty revision where the full acetabular component is replaced, and a new femoral head is placed, but nothing is done to the femoral stem?

Answer:

Thank you for asking KZA!

Admittedly, this is a frustration.

The CPT descriptor for 27137 is for revision of hip arthroplasty, acetabular component only. Based on the scenario described, it would not be appropriate to report 27137, as both the acetabular component and femoral head were revised.

The CPT descriptor for 27134 is for revision of hip arthroplasty, both components. A hip arthroplasty comprises the acetabular and femoral components (femoral head and femoral stem).

From a correct coding standpoint, both hip arthroplasty components have not been completely revised – we only have the acetabular and part of the femoral component (femoral head). Therefore, it would be appropriate to append modifier 52 to reflect the reduced services.

At the time of this writing, this is the current guidance from CPT.

*This response is based on the best information available as of 7/31/25.

ICD-10 - Skin Necrosis Following Breast Reconstruction

Question:

I’m having difficulty with the ICD-10 code assignment. Can KZA provide some guidance? A patient following breast reconstruction presented during the postoperative period with skin necrosis at the incision site.

Answer:

Thank you for your question!

Based on the information provided, two ICD-10 codes would be reported: one for the postoperative complication of the skin and subcutaneous tissue, ICD-10 L76.82, and one for skin necrosis, ICD-10 I96.

Some may stop at L76.82 alone. However, ICD-10 provides additional instruction located under L76.8. The instruction states, “Use additional code, if applicable, to further specify the disorder.”

*This response is based on the best information available as of 7/31/25.