63081 or Something Else?

Question:

I received feedback from an external review and am now confused. A partial cervical corpectomy (30%) was documented and reported with CPT 63081, along with fusion and instrumentation. I’ve been informed that this is not a corpectomy. I'm looking for confirmation that this is correct feedback.

Answer:

Thank you for asking KZA!

CPT defines the minimum amount of bone removed for partial corpectomies—the minimum amount for the cervical spine is at least one-half (50%).

The feedback received is correct, as the documented 30% does not support reporting a partial corpectomy. Instead, this is appropriately reported as an ACDF, CPT 22551.

*This response is based on the best information available as of 8/14/25.

Coding for Inspire

Question:

How do we go about coding the new Inspire V that has only a stimulation lead and no sensing lead? Also, how would we code a revision from Inspire IV to Inspire V?

Answer:

The new Inspire V system received FDA approval on August 2, 2024 and is coded using CPT 64568, which describes the open implantation of a cranial nerve neurostimulator and pulse generator. This is appropriate because Inspire V includes only a stimulation lead, unlike Inspire IV, which includes both a stimulation and a sensing lead and is coded as 64582.

For revisions from Inspire IV to Inspire V, the correct code is CPT 61885. This code is used for the replacement of a cranial neurostimulator pulse generator with connection to a single electrode array, which accurately reflects the Inspire V configuration. Other revision codes assume the same device architecture and are not appropriate when transitioning from a dual-lead to a single-lead system. Coders can identify the use of Inspire V in the operative note by the absence of a sensing lead, and by the fact that the procedure does not require dissection through the pectoralis muscle both of which you may see involved in an Inspire IV operative note. 

From a reimbursement perspective:

• Medicare has revised NCD 160.18 to allow ICD-10 code G47.33 (Obstructive Sleep Apnea) to be billed with CPT 64568. This change was implemented on July 1, 2025, but is retroactively effective to January 1, 2025. Additionally secondary diagnosis requirement of BMI are still required to support medical necessity.

• While many commercial payers have adopted this coding alignment, some have not, so it is essential to verify coverage and coding acceptance with each payer individually.

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 13939, documented in:

• MM13939 – ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2025 Update (PDF)

• R13097OTN – CMS Manual System Transmittal

*This response is based on the best information available as of 8/14/25.

I&D for Cutaneous Abscess

Question:

I am new to Dermatology coding and need help with this procedure note: An I&D was performed on the left hand for a cutaneous abscess. Consent was obtained and risks were reviewed including but not limited to delayed wound healing, infection, need for multiple I and D's, and pain. The area was prepped in the usual clean fashion. Local anesthesia was achieved with 2 cc of 1% carbocaine. The abscess was incised with a 15 blade, and pressure was applied to the wound to drain the underlying contents. Aquaphor and a dry sterile dressing were applied and wound care was reviewed. Can you tell me what CPT code I should use?

Answer:

Welcome to Dermatology coding! We are happy to help you. In this note, the physician is performing an incision and drainage. The physician incised the abscess and drained the abscess. Typically, a simple I&D involves a single lesion or abscess just below the skin’s surface. The correct CPT code to report is 10060 (incision and drainage of abscess) and the diagnosis code is L02.512 (Cutaneous abscess of left hand).

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

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.