eTEP Hernia Repairs

Question:

Our provider is doing hernia repairs with an eTEP which was explained to me as a myofascial advancement. Is this separately billable or is it considered bundled to the hernia repair?

Answer:

eTEP (extended or enhanced view totally extraperitoneal) describes the surgical approach utilized for the procedure. The coding for anterior abdominal hernia repair remains the same regardless of the approach performed. The appropriate repair code should be selected based on whether the hernia is initial or recurrent, as well as the total defect size.

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

SI Joint Injection in an ASC Coding

Question:

Does Medicare require a different code than 27096 for SI joint injections billed to an ASC?

Answer:

Yes. For ASC (Ambulatory Surgery Center) billing, Medicare requires HCPCS code G0260 for facility billing instead of 27096. For professional (physician) billing, use 27096. Remember to always verify payor-specific requirements.

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

Coding for a Fess Procedure

Question:

What is the recommended CPT coding for a nasal/sinus endoscopy with a total ethmoidectomy, frontal sinus exploration with removal of tissue from frontal sinus, a sphenoidotomy with removal of tissue from sphenoid, and a maxillary antrostomy with removal of tissue from maxillary sinus?

Answer:

For a functional endoscopic sinus surgery (FESS) involving the procedures you listed, the recommended CPT codes are:

• Total ethmoidectomy (anterior + posterior): 31259 – Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) including sphenoidotomy, including removal of tissue from the sphenoid sinus.

• Frontal sinus exploration with removal of tissue: 31276 – Nasal/sinus endoscopy, surgical; with frontal sinus exploration, including removal of tissue from frontal sinus.

• Maxillary antrostomy with removal of tissue: 31267 – Nasal/sinus endoscopy, surgical; with maxillary antrostomy, with removal of tissue from maxillary sinus.

CPT code 31259 is a combination code that includes anterior and posterior ethmoidectomy and the sphenoidotomy which includes the removal of tissue from the sphenoid sinus. These codes are separate and distinct procedures because they involve different sinus cavities, so they are typically reportable together (when medically necessary and documented). If performed bilaterally, append modifier -50 (or follow payer-specific bilateral reporting rules). The “with removal of tissue” codes (31267, 31276, 31259) are appropriate since tissue removal is documented. Do not separately report diagnostic endoscopy (31231) — it is included in the surgical procedures.

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

Biopsy of Lip

Question:

A provider performed a shave biopsy of the vermillion border using a dermablade. Would you report 11102 or 40490 for cases like this? What warrants reporting CPT Code 40490?

Answer:

Thank you for your question. For a shave biopsy of the lip skin or vermillion border performed with a dermablade, 11102 is the correct code. CPT 11102 covers tangential (shave/scoop/curette) biopsies of skin and skin appendages, which includes the cutaneous lip and vermillion. A dermablade is the classic instrument for a tangential/shave technique, which maps directly to the 11102 description. The lip, for integumentary coding purposes, is treated as a skin site when the biopsy involves the surface epithelium/vermillion using a shave technique

In order to report CPT code 40490 (biopsy of lip), the biopsy requires incisional technique into the deeper lip tissue (submucosa, muscle). The lesion is on the mucosal surface of the lip (wet mucosa, not vermillion or skin). A punch or excisional approach is used on the lip mucosa and the clinical intent is to sample submucosal pathology (e.g., suspected mucocele, minor salivary gland lesion, deeper fibrosis).

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

ICD-10 – Defect following Mohs

Question:

Can you please advise? Our practice performs reconstructions of defects following Mohs surgery. For context, we typically evaluate the patient prior to surgery to discuss reconstruction. What is the appropriate ICD-10 coding to reflect this wound in the setting of reconstruction?

Answer:

To accurately report this scenario, multiple ICD-10 codes are required:

1. Z48.1 - Encounter for planned postprocedural wound closure.

2. Z42.8 - Encounter for other plastic and reconstructive surgery following a medical procedure.

A third ICD-10 code should be selected based on the patient’s diagnosis history, specifically whether there is an active malignant neoplasm or a personal history of neoplasm.

Example: Same Day Mohs surgery and reconstruction

1. Z48.1 – Encounter for planned postprocedural wound closure.

2. Z42.8 – Encounter for other plastic and reconstructive surgery following a medical procedure.

3. Appropriate C-code for the malignancy.

Key Considerations:

• The malignancy code is not listed as the primary diagnosis because the service being performed is reconstruction, not treatment of the cancer.

• Codes from Chapter 19 of ICD-10 (S00–T88, injury range) are not appropriate, as they are designated for traumatic injuries and do not apply in this clinical context.

Thank you for reaching out to KZA with your inquiry.

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

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.