Office Visits, Unna Boot Application, and Wound Debridement

Question:

Could you provide guidance regarding office visits, the use of an Unna boot or Profore (application or removal), and wound debridement at the time of the visit? I am unclear if the codes for Unna boots, office visits, and debridements on the same day are mutually exclusive, need special modifiers, or flat out cannot be billed simultaneously. Thank you.

Answer:

When the purpose of the visit is to remove an existing Unna boot or Profore, perform wound debridement, and apply a new Unna boot or Profore, an E/M service should not be reported, as the evaluation and management work is inherent to the wound care procedures. An E/M service may only be reported, with modifier 25, when a separate, significant, and identifiable condition is evaluated and managed beyond the wound itself.

Medicare states that all supply items related to an Unna boot are included in CPT code 29580. When debridement and Unna boot application are performed on the same anatomic area during the same encounter, only the debridement is reimbursable; if no debridement is performed, only the Unna boot application may be reported. The NCCI Policy Manual for Medicare Services, Chapter 4, Section G, prohibits reporting debridement codes 11042–11047 or 97597 with codes 29580 or 29581 for the same anatomic area.

*This response is based on the best information available as of 01/22/26.

Reduction of Hernia Sac

Question:

General surgeon performs a laparoscopic repair of a hiatal hernia, reducing the hernia sac, constructs a Toupet fundoplication, and places mesh. He states 43282 can be reported regardless of the "type" of hiatal hernia, because the work is the same. Is he correct, and 43282 can be reported for repair of a sliding Type 1 hiatal hernia?

Answer:

Great question! Reduction of the hernia sac and a fundoplication does not automatically support code 43282. Code 43281 without mesh and 43282, with mesh, require the work to repair a true paraoesophageal hernia, not a less complex hiatal hernia. The documentation should describe the additional work needed, for example reducing the stomach from the thoracic cavity.

*This response is based on the best information available as of 01/22/26.

Sigmoid Sinus Resurfacing During Mastoidectomy

Question:

I have an ENT provider that performed a Mastoidectomy (69502) with sigmoid sinus resurfacing for pulsatile tinnitus. What CPT would I use for the sigmoid sinus resurfacing using bone cement and dust?

Answer:

A standard cortical mastoidectomy includes exposure and skeletonization of the sigmoid sinus. When additional work is performed to resurface or reconstruct a dehiscent sigmoid sinus for pulsatile tinnitus, this typically represents increased complexity of the mastoidectomy and is best reported with modifier 22 appended to CPT 69502 (or 69601 for revision cases). Because CPT does not provide a specific code for sigmoid sinus resurfacing and the work is performed through the mastoid, an unlisted code may need to be used in situations where the operative work is extensive and cannot be reasonably captured with modifier 22. Bone dust or bone pate obtained incidentally from mastoid drilling is considered local bone and is included when no separate donor incision is made. Bone cement is reported by the facility using the appropriate HCPCS supply code and is not separately reported by the physician.

*This response is based on the best information available as of 01/22/26.

X-Ray Coding: Is it the Hip or the Pelvis?

Question:

Can someone please answer the question of if the AP pelvis view is counted as a few when coding hip codes? For example, AP pelvis then 2 individual pictures of each hip AP & Lat; would this be coded as a 73523 (1V pelvis + 2V LT + 2V RT) or would this be coded as 73521 (AP and Lateral Views)? How would you code AP pelvis and 1V of LT Hip? 73501 since it is 1V Hip including AP Pelvis or 73502? There is conflicting information about whether you count the Pelvis as a view and whether you count the individual views done for each side.

Answer:

Thank you for reaching out. If you are performing AP pelvis then 2 individual pictures of each hip AP & Lat; you would code 73523 Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views.  This is consistent with the AMA's Clinical Examples in Radiology guidelines from fall of 2015.

*This response is based on the best information available as of 01/22/26.

Are There Special Documentation Requirements for an Assistant-at-Surgery?

Question:

We are seeking your advice on how to report to an assistant during surgery and what should be documented.

Answer:

Great question—this comes up often!

Two key points:

• If you are the assistant surgeon, you should not be dictating the operative note. That responsibility belongs to the primary or attending surgeon of record.

• The attending surgeon should include the assistant surgeon’s name in the designated assistant surgeon field and document the assistant’s role, providing details that support medical necessity.

Key takeaway: It is not sufficient to state, “Dr. XYZ assisted due to complexity.” This lacks specificity regarding the assistant’s role and does not describe the activities performed. Documentation should clearly outline what the assistant contributed during the procedure.

Determining the appropriate assistant modifier: both modifiers 80 and 82 indicate Assistant Surgeon. Modifier 82 is used explicitly in teaching hospitals with approved Graduate Medical Education (GME) programs for residents. In these settings, documentation must also confirm that no qualified resident was available to assist—this allows another physician to serve as the assistant surgeon, and modifier 82 should then be appended to that assistant surgeon’s claim.

In closing, please refer to your internal coding compliance guidelines to ensure adherence to the standards established by your compliance department.

Thank you for reaching out to KZA regarding your inquiry.

*This response is based on the best information available as of 01/22/26.

Help! Can You Clarify Radiology Documentation Requirements?

Question:

We are just looking for clarification of the Interpretation for Radiology services. We have been including them in our E/M notes for years. Can you please explain exactly what it is payors like UHC are requesting/requiring? Are they wanting a report of that Radiology exam on a separate form altogether?

Answer:

You're not the only one who has been including the interpretation in the E/M.

CPT guidelines in the introductory section of the radiology chapter 70000-79999 states a written report signed by the interpreting individual is considered "an integral part of a radiologic procedure or interpretation." This means radiology interpretation requires formal, separate documentation—not just findings mentioned within an E/M note. The written report must contain interpretive findings and documentation of the imaging performed.

The CPT exception is if the CPT code includes imaging. For example, CPT 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting includes image guidance. Since the imaging is part of the procedure, you document the imaging guidance within your procedure note rather than as a separate radiology report.

This is also consistent with CMS where the payment conditions for radiology services where Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures states: "The interpretation of a diagnostic procedure includes a written report.”

*This response is based on the best information available as of 01/22/26.