Secondary Closure?

Question:

I’m a new coder, and my physician closed a fasciotomy wound. I’m unsure what to do with this, so I am seeking some much-needed guidance. I’m looking at 13160. The surgeon debrided tissue and closed the wound.

Answer:

Thank you for reaching out—great job identifying CPT 13160. You're on the right track. If this is a secondary closure of a fasciotomy wound, CPT 13160 (Secondary closure of surgical wound or dehiscence) is appropriate.

*This response is based on the best information available as of 10/09/25.

Halo Adjustment?

Question:

What CPT code should be used to adjust a Halo device without anesthesia on postoperative Days 1, 2, and 5? CPT code 20664 was used to bill for the initial application of the Halo device. These adjustments are being performed in preparation for an upcoming surgery.

Answer:

Thank you for reaching out to KZA!

CPT codes 20664 and 20661 both include the application and removal of the Halo device. Any adjustments made during the 90-day global period following the initial procedure are considered part of the global surgical package and are not separately reportable.

*This response is based on the best information available as of 10/09/25.

Modifier 59 vs Modifier 51

Question:

Can you clarify when to use modifiers 59 vs 51?

Answer:

Modifier 59 (or X modifiers) should only be used for a bundling edit to unbundle two codes that are not usually reported together but are appropriate under specific circumstances. If there is no bundling edit between two codes, then modifier 51 is appended to the second code to indicate an additional procedure.

*This response is based on the best information available as of 10/09/25.

Reporting Modifiers with Unlisted Codes

Question:

Can modifiers be reported with unlisted CPT codes?

Answer:

Yes, modifiers can be appended to unlisted CPT codes.

In 2024, CPT clarified this by updating the introduction guidelines for unlisted procedures and services. These updates were further explained in the January 2024 issue of CPT Assistant, which addressed the new and revised text and the standardization of reporting unlisted CPT codes across the CPT code set.

Illustration of modifiers that may be appropriately applied includes:

• Laterality modifiers – e.g., RT (right), LT (left)

• Bilateral procedure modifier – 50

• Role-based modifiers – e.g., 62 (two surgeons), 80 (assistant surgeon), 82 (assistant surgeon when qualified resident not available), AS (non-physician surgical assistant)

• Multiple or distinct procedure modifiers – e.g., 51 (multiple procedures), 59 (distinct procedural service)

• Global modifiers – e.g., 58 (staged or related procedure), 78 (return to operating room for related procedure), 79 (unrelated procedure or service)

This is not an all-inclusive list of modifiers that may be appropriately applied to unlisted CPT codes. For complete and up-to-date information, one should refer to current CPT guidelines and payer-specific policies.

Please note: Modifiers that describe an alteration of a service or procedure, such as modifier 52 (reduced services), are not appropriate for use with unlisted codes. The same applied to modifier 22 (increased procedural services).

*This response is based on the best information available as of 9/22/25.

Clarification for TLIF with Contralateral Posterior Fusion Using Robotic Navigation

Question:

I am looking for guidance on a Transforaminal Lumbar Interbody Fusion (TLIF) case using robot/navigation. Placing a posterior fusion on the contralateral side of the spine from the TLIF. He is using the robot to plan a "false" screw then using robot to drill the opposite facet and then place bone graft into the facet. It requires additional time both before and after procedure. Would this be coded as 22612 along with 22633?

Answer:

Thank you for your question. If the contralateral posterior fusion is performed at the same level as the TLIF and is considered part of the same interspace, then CPT 22633 alone should be reported. This code already includes both the posterior interbody fusion and the posterolateral fusion at a single level. Even if robotic navigation is used to access the contralateral facet and place bone graft, it does not justify separate coding with 22612. 

*This response is based on the best information available as of 9/25/25.

J3301 Triamcinolone Billing

Question:

When billing HCPCS code J3301 Triamcinolone acetonide injectable suspension (Kenelog), if 40 mgs are injected, do I bill J3301 x 4 units or J3301 x 40 units?

Answer:

HCPCS code J3301 triamcinolone acetonide injectable suspension, not otherwise specified, (Kenalog) is billed based on 10mg dosage. If 40 mgs are injected, it would be coded with J3301 x 4 units.

Do not confuse this with HCPCS J1030 Depo Medrol which changed in 2024 and is now coded for 40 mg as J1010 x 40 units.

*This response is based on the best information available as of 9/25/25.