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.

Use of 15740 for Closure Following Pituitary Tumor Excision

Question:

My physician performed a pituitary tumor excision and reported CPT code 62165-62. The ENT surgeon also performs a pedicled flap (15740). The neurosurgeon performs a fat graft for the closure. Can 15740 also be billed for the ENT surgeon, and if so, would a 59 modifier be needed?

Answer:

In skull base cases, when the ENT harvests a nasoseptal flap to repair or prevent a cerebrospinal fluid (CSF) leak during an endoscopic pituitary excision, this work is considered part of the procedure. According to CPT Assistant (December 2017, page 14), closure of a CSF leak—including the use of a nasoseptal flap—is included in the work described by 62165 and should not be separately reported. Therefore, 15740 would not be separately billable in this scenario, and modifier 59 would not apply.

*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.