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E/M Coding Based on Time
When choosing the level of E/M we are confused about the History and Exam. If we choose a level of E/M based on time, does this time count toward total time, or is it only time spent on MDM?
Selecting Skull Base Surgical Approaches
How should we bill for a skull base surgery approach when the surgeon accessed both the middle and posterior cranial fossae (e.g., CPT® 61591 and 61595), and the main lesion was resected from the posterior cranial fossa (e.g., CPT® 61616)?
Angioplasty vs. Stent Placement
Our providers are using a self-expanding scaffold system that features integrated balloon dilation. This device is designed to temporarily support the artery, widening blockages, but the scaffold is retrieved at the end of the procedure, so no permanent implant remains. Such technology represents an innovation for treating peripheral artery disease, especially in cases with complex, calcified narrowing of lower limb arteries. Given that the scaffold is temporary and removed, my coding research indicates this procedure should be reported as angioplasty. Some device vendors suggest billing as stent placement. Is this accurate?
Since it leaves no implant behind my coding research states to use angioplasty-vendor states bill as stent?
Coding Conundrum: Coding for Facet Cyst Aspiration
We are confused by AMA recommendations for the aspiration of a facet cyst. While researching, we found two CPT Assistants (2011 and 2017) advising to use an unlisted code, 64999. The Clinical Examples in Radiology CPT Assistant, February 2024 instructs to use CPT code 22899, not 64999. The rationale cited for recommending CPT code 22899 is because the procedure does not involve entering the facet joint and facet cysts are not considered to originate in the nervous system.
Which unlisted code does KZA recommend?
Excisional Debridement (1104x) vs. Surgical Preparation (1500x)
Our surgeon is taking a patient to the OR to excise a surgical wound dehiscence, which will be closed with a skin graft. We are looking at debridement codes 1104x and the skin graft codes (15xxx). Are we on track?
Complex Close with FTSG
We want to confirm with KZA if a complex closure with extensive undermining is required to close the donor site where an FTSG was taken. Can we separately report the closure?
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