Tibial Plateau Fractures

Question:

Can you please clarify if CPT 27536 requires two incisions, one for the medial and one for the lateral to be able to use this code?

Answer:

While the common approach to a bicondylar tibial plateau fracture is by two incisions, one medial and one lateral, it is not required. The bicondylar fracture can be treated by a single midline approach for dual plating. 

What is important it that a bicondylar tibial fracture is being treated.  

CPT description reads: CPT 27536 Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation.

*This response is based on the best information available as of 04/02/26.

Transcarotid TAVR: Unlisted Code 33799

Question:

My hospital wants to pursue elective TAVR via carotid approach. Normally via percutaneous femoral approach, the Interventional Cardiologist and Cardiac Surgeon bill for the case. If they request me for open carotid artery exposure (as Vascular Surgeon), is there a way for me to bill as a third provider?

Answer:

There is currently no specific CPT code for transcarotid TAVR, so the entire procedure is reported using unlisted cardiac surgery code 33799. When submitting 33799, it is best practice to include a crosswalk to the comparable TAVR code range 33361–33366 to support valuation and reimbursement. Because all TAVR/TAVI codes include vascular access, exposure, and closure as bundled components, separately billing for access (e.g., carotid cutdown or repair) would not be appropriate. TAVR procedures are intended to be performed by two co-surgeons—a cardiothoracic surgeon and an interventional cardiologist, who each report the procedure using modifier 62 (co-surgery). If a vascular surgeon, participates in the case for carotid exposure, the only potential billing pathway would be to attempt team-surgery reporting (modifier 66). However, this is not always accepted and would require that the payer recognizes the team-surgery model and that documentation supports the medical necessity of both the carotid approach and the involvement of all participating surgeons. Because the carotid approach remains an unlisted service, obtaining payer preauthorization or a pre-determination of coverage is strongly recommended to confirm acceptance of both the unlisted code (33799) and the team-surgery structure before scheduling an elective case.

*This response is based on the best information available as of 04/02/26.

CPT 42160 for Laser Ablation of a Soft Palate Papilloma

Question:

Can CPT code 42160 be used for a laser ablation of the velum surface of the soft palate papilloma (ie. is the laser considered thermal)?

Answer:

CPT 42160 is reported based on destruction of the lesion. If the documentation supports destruction of a soft palate papilloma, laser ablation qualifies as a thermal technique and meets the criteria for the code.

*This response is based on the best information available as of 03/05/26.

Clarification on Consultation Codes

Question:

After reviewing the First Patient Encounter question and answer. Would this still be considered a consult since the problem is already established with the provider? "The admitting physician has asked me to see the patient again for that same condition" New vs established does not pertain to IP/Consult codes. However can they bill a consult on an established diagnosis?

Answer:

Consultation codes may be used for patients previously seen for the same condition, provided the provider did not assume ongoing care during prior encounters and is not assuming management in the current hospitalization. The key distinction lies in seeking an opinion or advice versus assuming care and management of the condition. To report a consultation, a formal physician request must be documented, a clinical evaluation and recommendations must be provided, and findings must be communicated back to the requesting provider. Previous encounters do not disqualify the use of consultation codes if these requirements are met and the current request genuinely seeks consultation rather than care management. However, if the provider is already treating and managing the condition, consultation codes are not appropriate when the requesting provider asks them to see a patient already under their active care.

*This response is based on the best information available as of 03/05/26.

Osteotomy & Laminectomy Same Level

Question:

I have a question about a complicated surgery and was hoping to get some feedback, as I've been receiving mixed responses and want to ensure these procedures are being reported accurately. Am I able to report any laminectomy that overlaps at the same levels as spinal osteotomies?

Answer:

Great question! Spinal osteotomy is performed to correct spinal deformity and includes laminectomy and decompression at the same level. Because these components are considered inherent to the osteotomy procedure, it is not appropriate to report the laminectomy separately at the same level.

To ensure accurate coding, the operative report should clearly document:

• The type of spinal deformity

• The degree of correction being sought by osteotomy

• Details of how the osteotomy was performed

• The resulting changes from osteotomy

 If the documentation supports spinal osteotomy, it encompasses the laminectomy at that level.

 Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 03/05/26.

Epidermoid Cyst

Question:

My physician removed an epidermoid cyst and I am not certain how to code this. What CPT code is used for the removal of a 1.2 cm epidermoid cyst on the scalp that is removed through a small linear incision, is dissected and removed in total. I think I should use the I&D code 10060 but I am not sure. Can you help?

Answer:

Thank you for your question. Because the cyst was removed through a small linear incision, dissected free and removed in total (en bloc) from the scalp, this meets the definition of a benign lesion excision not an incision and drainage (I&D). The correct CPT code based on the 1.2cm size and anatomic location is 11422 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm).

*This response is based on the best information available as of 03/05/26.