Evaluation and Management Service in the Office - Based on Time

Question:

What should be documented when reporting an E/M service based on time in the office?

Answer:

When reporting an E/M (Evaluation and Management) service based on time, documentation must clearly support that time, not medical decision-making, is the controlling factor.

Key elements that must be documented:

• Total time spent

  • Document the total number of minutes personally spent by the provider on the date of the encounter.

  Documentation Example: “I spent a total of 45 minutes on this patient’s care today, including reviewing prior records, evaluating the patient, counseling on diabetes management, adjusting medications, and documenting the encounter.”

• Activities performed

  • You should indicate the types of activities included in that time, such as:

    • Reviewing tests/history before the visit.

    • Obtaining history and performing an exam.

    • Counseling and educating the patient/family.

    • Ordering medications, tests, or procedures.

    • Communicating with other healthcare professionals.

    • Documenting in the EHR.

    • Care coordination.

• Date specificity

  • Time must reflect work performed on the same calendar date as the encounter. Time spent on procedures must be excluded from the E/M time. Time spend on procedures must be excluded from the E/M time.

• Provider-specific time

  • Only include time personally spent by the billing provider (and qualified healthcare professionals if applicable per payer rules).

  • Exclude time spent by ancillary staff.

• Medical necessity

  • Documentation should still support why the visit was necessary (chief complaint, reason for care), and a medically appropriate history and/or examination.

  • A summary of counseling/topics discussed can strengthen the record.

Exact start/stop times are not required (total time is sufficient).

*This response is based on the best information available as of 06/04/26.

63048 Clarification

Question:

Hello! My question is regarding CPT coding. Is CPT 63048 an add-on to 63052?

Example: L3-L4 TLIF w/ Laminectomy, L4-L5 Posterior Instrumentation Fusion w/ Laminectomy.

Would this be coded as:

• 22633, 22614, 63052, 63047

OR

• 22633, 22614, 63052, 63048

Answer:

CPT code 63048 is an add-on code to be used in conjunction with CPT codes 63045, 63046, and 63047 – not with 63052.

Based on the scenario, and provided the documentation supports reporting decompression at both levels/interspaces, the appropriate coding would be:

• 63052 for the interbody level (TLIF at L3/L4)

• 63047 for decompression at L4/L5

Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 06/04/26.

What’s Included and Excluded in an ALIF

Question:

Hi, I have a spine surgeon and vascular surgeon working together on an ALIF procedure, 2 level, which I have billed 22558/22585. The vascular surgeon is also repairing the sympathetic nerve, which i don't see a code for. He has input 64722 but I'm not quite sure that would be the correct code. Also, would that not be part of the ALIF procedure? He is also starting to bill and code the repair of the middle sacral vein, sacral artery, and iliolumbar vein. I looked at those codes at 35221, now I put those through the NCCI edits, and it seems that it can be billed. However, I read through another coding forum that a provider can’t bill those codes, as that is part of the ALIF procedure. I need clarification on whether repairing artery or veins are part of the ALIF procedure.

Answer:

The question you pose is a complicated one without reviewing the operative report, therefore, here are some general guidelines.

If the vascular surgeon is providing the approach and not there to treat a complication during the ALIF procedure, the approach may include access through the the iliac vessels, parasympathetic nerves, and middle sacral artery. If there are incisions through any of these structures, then they are included and would not be billed separately.

*This response is based on the best information available as of 05/07/26.

Skin Tag Removal

Question:

Is it correct to report 11300-11313 for the removal of 4 skin tags by shave?

Answer:

In this scenario, the diagnosis determines the correct code selection. For skin tags, the appropriate codes are 11200–11201. The guidelines for these codes state, “Removal by scissoring or any sharp method,” which would include “shave.” Therefore, it would not be appropriate to report codes 11300–11313 (shaving of epidermal or dermal lesions) for this service. The removal of 4 skin tags would be correctly reported with 11200.

Thank you for reaching out to KZA!

*This response is based on the best information available as of 05/07/26.

Multiple Femoral Fractures

Question:

I am wondering about charging both CPT codes 27506 (femur shaft) and 27245 (femur intertrochanteric). There is an NCCI edit indicating that 27245 is included with 27506 per mutually exclusive procedures. The provider is saying these are two separate injuries/entities and we should use a modifier. However, I am not sure if that would be correct since they are both on the same bone, just different locations of it. Can you please explain if it would be appropriate to code both codes for the same femur? It seems they are using one nail to fix both fractures. What if they are two separate fractures, does that make a difference? I am having trouble locating any guidance for this scenario. Thank you for your insight.

Answer:

If one intramedullary implant is being placed to treat an intertrochanteric, peritrochanteric, or subtrochanteric fracture in addition to a femoral shaft fracture, only one code would be used. There is an NCCI edit stating that they are mutually exclusive procedures, and a modifier would not be appropriate to override the edit. 

Modifier 22 Increased Procedural Services may be appended if the documentation supports that the work required to treat the fractures was substantially greater than typically required. 

Code selection of either 27506 or 27245 should be determined by the provider based on which treatment was more extensive. 

*This response is based on the best information available as of 05/07/26.

Lipoma Question

Question:

If a surgeon excises a subcutaneous lipoma in the thigh and inadvertently violates the fascia, would the repair level be above the fascia or within the fascia for coding purposes?

Answer:

Great question. In this scenario, there would be no separate reporting for the repair. Excision of a subcutaneous lipoma of the thigh is coded using a procedure code from the 2xxxx series, and closure—whether above or at the fascia—is considered inherent to the excision and is not separately reported.

Thank you for reaching out to KZA!

*This response is based on the best information available as of 05/07/26.