Actively Assisting PA

Question:

What are the documentation requirements for a teaching physician when both a resident surgeon and a PA first assist are present in the operating room? The PA is actively assisting, and both individuals are noted in the operative report.

Answer:

In a teaching facility, if a resident acts as assistant and if that resident is considered (by the teaching physician) to be qualified to assist in the case, no third provider will be reimbursed as an additional assistant. If, however, the teaching physician attests that no qualified resident was available to act as an assistant, a PA may be billed as assistant. The resident may still be present for teaching purposes and listed as participating in the case.

The definition of “qualified resident“ is case specific. It may be that a resident is not physically available or that the available resident is considered (by the teaching physician) to not be clinically qualified for the specific operative case. A teaching facility’s compliance department may have specific language for an attestation statement.

*This response is based on the best information available as of 12/18/25.

Modifier Use and Same-Day Vascular Ultrasound Services

Question:

I have a question regarding the appropriate use of modifiers when billing for E/M services performed on the same day as ultrasound procedures (e.g., 93880, 93922, 93978, etc.). Our billing team has been consistently appending modifier 25 to all E/M visits that coincide with same-day ultrasounds, and applying modifier 59 to each ultrasound code. We are a private practice and own the ultrasound equipment, so we do not use modifiers 26 or TC. Could you please confirm whether this approach is correct? Specifically, is it appropriate to routinely apply both modifier 25 to the E/M service and modifier 59 to the ultrasound codes for all in-office visits involving same-day ultrasounds? Thank you in advance for your guidance!

Answer:

Based on NCCI data, there are no procedure-to-procedure edits between office visits and vascular ultrasound codes such as 93880, 93922, or 93978, meaning these services are not inherently bundled and may be reported together when medically necessary and supported by documentation.

Because there are no NCCI conflicts, the use of modifiers 25, 59, or XU is not required for these code combinations. However, some payers may still require one or more of these modifiers for claims processing or system recognition when an E/M service and diagnostic ultrasound are performed on the same day.

It is important to review individual payer policies to determine when modifiers 25, 59, or XU may be necessary to ensure accurate claim submission and avoid denials.

*This response is based on the best information available as of 12/18/25.

Collagen Patch

Question:

I would like to get your opinion on what A6023 documentation is needed for billing out collagen patches.  Should they be noting the sizes and changes of the wound at follow-up visits?

Answer:

Excellent question! CMS is very clear that documentation for the application of A6023 Collagen dressing, sterile, size more than 48 sq in, each requires a physician's signed order, details on the wound's type, location, size, drainage, and specifics about the dressing used (type, size, and frequency of change). The documentation must also demonstrate the medical necessity for the collagen dressing, which, for Medicare, requires the product to be listed on the Product Classification List (PCL) following a Coding Verification Review (CVR).

*This response is based on the best information available as of 12/18/25.

Lobectomy with Substernal Component

Question:

I have a coding question that I'm hoping you can help me out with. If a doctor removes only one lobe of the thyroid and also includes the substernal component, should 60271 or 60220-22 be used? Thank you!

Answer:

Unless a sternal split is performed, report 60220 for a thyroid lobectomy. Code 60271 request splitting the sternum. If documentation supports significant additional work, modifier 22 may be append to 60220.

*This response is based on the best information available as of 12/04/25.

Removal of a Patellar Tendon Ossicle/Tibial Tubercle Ossicle

Question:

Is there another CPT that code can be used for the removal of a patellar tendon ossicle/tibial tubercle ossicle or is an unlisted procedure code the only option? Any help you can provide will be greatly appreciated!

Answer:

Thanks for reaching out. Current CPT guidance for a patella tendon ossicle or tibial tubercle ossicle removal is unlisted CPT 27599.

*This response is based on the best information available as of 12/04/25.

Bone Marrow Aspirate

Question:

Good afternoon,
One of our physicians is performing an injection of bone marrow aspirate concentrate into infraspinatus, supraspinatus tendons and the glenohumeral joint, under ultrasound guidance. Bone marrow was aspirated from bilateral iliac crests under US guidance and processed via centrifugation. How should this be reported?
Thank you

Answer:

CPT Category III code 0232T was introduced in 2010 for reporting injection of platelet rich plasma to a targeted site; the code definition includes all harvesting, preparation, and image guidance for the service. In August 2010 the AAOS published guidance in AAOS Now which explained “The new code is to be used only when PRP is performed in a complete separate patient encounter from a surgical procedure.”

Based on this direction, when PRP is injected during another procedure, whether using drawn blood or bone marrow aspirate, it is not separately reportable with the primary surgical service.

If PRP injection is the only service performed, then 0232T is the correct code. In recent years some physicians have begun using bone marrow aspirate harvested from the iliac crest instead of drawn blood for PRP preparation, and reporting the harvesting using CPT code 38220. The May 2012 edition of CPT Assistant clarified that 0232T is the only code reportable for PRP injection, whether performed using drawn blood or harvested bone marrow aspirate. In 2018 the definition of 38220 was changed to reflect that it should be used only for diagnostic bone marrow aspiration. New code 20939 should be used when bone marrow aspiration is performed for bone grafting, for spine surgery only, via a separate incision. CPT instructs to use 20999 for bone grafting, other than spine surgery and other therapeutic musculoskeletal applications.

*This response is based on the best information available as of 12/04/25.