Repair of Pyloric Channel Ulcer with Graham Patch

Question:

Hello, we are reporting repair of pyloric channel ulcer with 43840 and the omental flap with 49905, we keep getting feedback from an external auditor that 49905 is not separately reportable. Could you please clarify how this procedure should be reported and the reasoning?

Answer:

Code +49905 is not reported separately when used to secure a suture line in an ulcer repair as you described, or for securing an anastomosis in colon resection as another example.

CPT code +49905, omental flap, intraabdominal, is intended for an omental flap to reconstruct a defect, for example after lesion resection, to fill an anatomic defect resulting from that resection.

*This response is based on the best information available as of 02/05/26.

Reporting an E/M Service on the Same Date as Mohs Surgery

Question:

I code for 2 Mohs surgeons and I am confused about whether or not we can code for an E/M service on the same day as Mohs. Here is the situation: The patient is referred by an outside Dermatologist and scheduled for Mohs surgery with one of our Mohs surgeons. The patient brings in a biopsy that was performed the previous week. Can we bill a new patient E/M visit since the physician has to evaluate the patient before performing Mohs?

Answer:

If the patient has been scheduled for Mohs surgery and the evaluation performed is the routine preoperative assessment necessary to perform the procedure, do not bill the E/M service. The E/M service is inherent to Mohs surgery. The E/M service is only billable if it goes beyond the inherent preoperative work, meaning it must be significant and separately identifiable and well documented in the medical record.

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

Coding Clarification: Instrumentation Removal vs. Exploration Based on Intent

Question:

Good afternoon,

I recently came across one of your Q&As from June 2025 that stated when spinal instrumentation is removed for the purpose of exploration, we would code the exploration CPT code 22830. This is helpful information; however, I am wondering if you can provide a reference for this. I would love to pass this information along to our providers, and a solid source would help to support it.

Answer:

In June 2025, the coding question was clarified:

CPT code 22830 should be billed if the intent for the procedure was for exploration.

If the intent is to explore the spinal fusion site, and instrumentation is removed only to allow that exploration, then CPT 22830 is reported. If the true intent is to remove the instrumentation (e.g., due to pain, infection, or hardware failure), and exploration is incidental, then only the instrumentation removal code is reported.

The National Correct Coding Initiative (NCCI) bundles certain codes based on the principle of standards of medical/surgical practice, which means: If a service is routinely performed as part of another procedure, it is considered integral and not separately reportable.

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

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.