CPT 95865

Question: When performing electromyography (EMG) on cranial nerve supplied muscles via the endotracheal tube sticker electrode, the sticker electrode measures one channel of EMG from both sides. Thus, it is bilateral monitoring with a single channel. Would that be considered unilateral (95867) or bilateral (95868)?

Answer:

Code 95865, Needle electromyography; larynx, should be reported as opposed to 95867 or 95868. Code
95865 represents inherently bilateral recording.

CPT 93623

May code 93623 be reported for an isoproterenol study postablation following a single catheter electrophysiologic study with induction of arrhythymia, ablation of supraventricular tachycardia, and postablation injection of isoproterenol?

Answer:

Although it is extremely unusual to record and pace from only one or two sites within the heart, there
are still occasional circumstances for which singlecatheter studies for either recording and/or pacing
might be undertaken. Because code 93623, Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure), is reportable only in conjunction with 93619 and 93620, code 93624, Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia, is reported to describe follow-up electrophysiologic study of the efficacy of any therapy undertaken, including any therapy initiated, whether pharmacologic, surgical, or catheter ablation, or device therapy.

Also reportable is code 93618, Induction of arrhythmia by electrical pacing, which is used to report insertion of a single catheter for the purpose of inducing an arrhythmia. This procedure is rarely performed in and of itself because, in most instances, further evaluative studies and mapping of the arrhythmia would also be performed. Code 93651, Intracardiac catheter ablation of arrhythmogenic focus; for
treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination, is reported to describe the catheter ablation procedure.

Modifier 51 should not be appended to 93600, 93618, 93621-93623, and 93631.

Can CPT 96365 be used twice during the same visit ?

 A patient is admitted to observation and the physician orders an antibiotic IVPB administered over one hour and repeated every eight hours. The patient receives the first dose from 12 pm to 1 pm and the next dose from 8 pm to 9 pm. Would this be reported with codes 96365 and 96367?

Answer:
The facility may report code 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify sub-
stance or drug); initial, up to 1 hour, for the first intravenous infusion of the antibiotic and code 96367, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure), to reflect the second antibiotic infusion.

The rationale for reporting both codes 96365 and 96367 relates to the use of only one initial service code
per IV site per encounter. The observation stay for that date would be considered a single encounter, for which 96365 and 96367 are reportable.

CPT 87804

Please clarify whether reporting code 87804 two times, once with modifier 59 (87804, 87804 59), would
be appropriate for differentiating rapid influenza tests; those providing separate, distinct results for both strains A and B on one device.

Answer:
The detection of both influenza A and B strains may be part of two entirely separate procedures or may be
included within the same test device because these two analyses are not uncommonly requested by the clinician together. If the assays provided two separate results (eg, a result for influenza A and a result for influenza B), two units of 87804 would be appropriate. Modifier 59, Distinct procedural service, may be used to indicate that the two results represent separate services, when two units of 87804 are submitted.

CPT 86945

Can we report 86945 when the patient requires irradiated platelets per the attending physician order (even though the product was not actually irradiated for that specific patient)? Can we report 86945 when the clinical record indicates the patient does not require irradiated platelets (ie, the attending physician does not order irradiation)?

Answer: 
Yes, you may report code 86945, Irradiation of blood product, each unit, when the patient requires
irradiated platelets per the attending physician order even though the product was not actually irradiated for

that specific patient. It would not be appropriate to report code 86945 in the event the blood bank-transfusion service has chosen to irradiate all platelets when (a) it might not be indicated and/or (b) a physician order for that irradiated product (the only product stored, having irradiated them all) is lacking.

CPT 88285 chromosome analysis

Is it appropriate to report code 88285 per each additional cell counted beyond the number specified in the base code (eg, 88261 or 88262), or does it cover all additional cells counted for the study (ie, single test result)? For example, 10 cells are counted instead of five as specified in the descriptor.
Do I report code 88285 once or five times to account for the analysis of the additional cells?

Answer:

Code 88285, Chromosome analysis; additional cells counted, each study, should be reported once because the descriptor nomenclature indicates the analysis of additional cells (plural). Therefore, it would not be appropriate to report five units of code 88285 for the analysis of five additional cells.

Laboratory tests done more then once require which CPT modifiers?

Is it necessary to use modifier 59, Distinct procedural service, when laboratory tests contain the same CPT
code more than once? For example, flow cytometry studies may involve reporting 88184 and 88185 x3. Would modifier 59 be appended to the second and third use of 88185?

Answer:
From a CPT coding perspective, it is not necessary to append modifier 59, Distinct procedural service, to CPT add-on codes because these codes represent additional or incremental work associated with the basic procedure performed. Code 88185, Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first mark er), is an add-on code reported in conjunction with 88184.

What is the CPT for B-readings of chest X rays

How does one report B-readings of chest X rays (views include anteroposterior, lateral, and oblique)? Which CPT codes and/or modifiers should be used to report the film, its interpretation, and the B-reading?

Answer:
The radiologist should report the appropriate number of chest X-ray views with modifier 22, Increased procedural services, appended to indicate the increased complexity in reporting B-readings (ie, completion of form with five different sections and grade).

CPT for Pterygium excision with excision of inflammatory subconjunctival membrane

Pterygium excision with excision of inflammatory subconjunctival membrane and conjunctival rearrangement
was performed without a graft. Would it be appropriate to report 65420 and 68320? Is the conjunctival rearrangement included in 65420?

Answer: 
If, based on the clinical judgment of the surgeon, the conjunctival rearrangement is substantial, it would
not be considered inclusive of the procedure described by code 65420, Excision or transposition of pterygium; without graft. Therefore, in the event the conjunctival rearrangement is substantial, then code 68320, Conjunctivoplasty; with conjunctival graft or extensive rearrangement, is separately reportable.

What is CPT code for intravitreal insertion of a nonbiodegrad- able drug delivery implant

If performing intravitreal insertion of a nonbiodegradable drug delivery implant (without removal of vitreous) should code 11981, 67027, or 67299 be reported?

Answer:
Code 67027, Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant
removal of vitreous, should be reported with modifier 52, Reduced services, appended. The use of modifier 52 indicates that at the discretion of the physician a portion of the procedure as described was not performed. As indicated, “the removal of vitreous” was not performed.

What is the CPT code for phenol injections to the superior hypogas- tric plexus

How would phenol injections to the superior hypogastric plexus be reported when, following multiple-needle positioning attempts at the right and left L5 region, the procedure is discontinued due to the patient’s increased heart rate and suboptimal dye spread?

Answer:
Code 64681, Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric
plexus, should be reported once with modifier 53, Discontinued procedure, appended. Modifier 53 indicates
that due to extenuating circumstances or those that threaten the well being of the patient, the physician
elected to terminate a procedure.

CPT code for laser lithotripsy of ureteral calculus with ureteroscopy and ureteral catheterization

Does code 52353 include laser lithotripsy of ureteral calculus with ureteroscopy and ureteral catheterization?

Answer: Yes. Code 52353, Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included), includes the fragmenting of the stone with a laser lithotripsy through the ureteroscopy as well as the ureteral catheterization, if performed. If a cystourethroscopy without ureteroscopy is performed with lithotripsy to fragment ureteral stones, then code 52325, Cystourethroscopy including ureteral catheterization; with fragmentation of ureteral calculus (eg, ultrasonic or electro-hydraulic technique), should be reported.

What is the CPT code for change of a suprapubic catheter?

Is code 51705 the correct code to report for change of a suprapubic catheter?

Answer:

Yes. Code 51705, Change of cystostomy tube; simple, may be reported to describe the removal of an existing suprapubic cystostomy tube with reinsertion of a new tube through the established cystostomy tunnel from the abdominal wall to the bladder. Code 51710, Change of cystostomy tube; complicated, may also be reported if the removal and replacement of the suprapubic tube involves a more complex encounter. Code 51102, Aspiration of bladder; with insertion of suprapubic catheter, involves performance of a stab wound on the lower abdomen (approximately 1 cm) above the pubis. A trocar suprapubic tube is inserted into the bladder. The balloon is inflated and the tube sutured into place. This code should be reported for the initial insertion of the suprapubic catheter when performed as described.

What is the CPT code for a thorascopic total thymectomy

What is the correct code for a thorascopic total thymectomy?

Answer: 
Code 60699, Unlisted procedure, endocrine system, should be reported to describe a thorascopic total thymectomy. Code 32662, Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or mass, would not be appropriate as this code represents the type of surgical approach used, but not specifically the excision of the thymus. Code 60521, Thymectomy, partial or total; sternal split or transtho-
racic approach, without radical mediastinal dissection (separate procedure), represents the thymectomy, however, performed by an open surgical approach as opposed to thorascopic technique.
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What is the CPT code for removal of sludge during endoscopic retrograde cholangiopancreatogra

Question: During endoscopic retrograde cholangiopancreatography, is the removal of sludge considered the same as removal of stone(s)?

Answer: 
Yes code 43264, Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts, should be reported when, during the ERCP, the “removal of sludge” is performed.

What is the CPT code for injection of a radiosensitizing agent into the pancreas prior to radiotherapy treatment

How do you report injection of a radiosensitizing agent into the pancreas prior to radiotherapy treatment?

Answer:
There is no specific CPT code to describe this procedure. Therefore, code 48999, Unlisted procedure, pan-
creas, should be reported. It would not be appropriate to report add-on code 48400, Injection procedure for intraoperative pancreatography (List separately in addition to code for primary procedure).

What are the CPT codes for insertion and replacement of a percuta- neous jejunostomy tube

What is the correct code for insertion of a percutaneous jejunostomy tube? What is the correct code for replacement (tube change) of a percutaneous jejunostomy tube? What is the correct code for insertion of a percutaneous gastrostomy tube with conversion to a jejunostomy tube at the same session? What is the correct code if an existing gastrostomy tube is converted to a jejunostomy tube at a separate setting?

Answer:
CPT 2008 includes new codes for image-guided percutaneous tube placement, conversion and replace
ment. These codes all require image guidance as a necessary component of the procedure. Code 49441, Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report, should be reported for image-guided
percutaneous jejunostomy tube insertion. For image-guided replacement (tube change), code 49451,

Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report, should be reported.

If an existing gastrostomy, duodenostomy, or jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube is removed and a new tube is placed via a separate percutaneous access site, the placement of the new tube is not considered a replacement and would be reported using the
appropriate initial placement codes 49440-49442.

If a gastrostomy tube is placed using image guidance and subsequently converted to a jejunostomy tube at
the same setting, both codes 49440 and 49446 are reported. If an existing gastrostomy tube is converted to a jejunostomy tube at a setting separate from the initial gastrostomy tube placement, then only 49446 is reported for the conversion because 49440 would have been reported for the initial placement of the gastrostomy tube performed at a prior setting.

What is the CPT code for laparoscopic excision of a gastric lesion

How would each of the following procedures be reported: (1) laparoscopic excision of a gastric lesion, (2) laparoscopic partial gastrectomy, and (3) laparoscopic partial gastrectomy with a jejunostomy?

Answer: 
There are no specific CPT laparoscopic codes to describe these laparoscopic procedures. Code 43659,
Unlisted laparoscopy procedure, stomach, should be reported to describe each of the three procedures listed.

CPT code for laparoscopic wedge liver biopsy with laparoscopic cholecystectomy

What is the correct code to report a laparoscopic wedge liver biopsy with a laparoscopic cholecystectomy?

Answer:
 The laparoscopic cholecystectomy is reported using an appropriate code from the 47562-47564 series.
There is no specific CPT code to describe laparoscopic wedge liver biopsy. Code 47379, Unlisted laparoscopic procedure, liver, should be reported without any CPT modifier. Because unlisted codes do not include descriptor language that specifies the components of a particular service, these codes are reported without modifiers.

How is code 75898 reported in conjunction with transcatheter embolization?

How is code 75898 reported in conjunction with transcatheter embolization? Is it reported for each follow-up angiogram performed, only once for each individual vessel embolized, or only once for the entire operative site embolized?

Answer:
Unlike angioplasty, completion angiography is not included in embolotherapy and infusion therapy.
With the exception of the intracranial or central nervous system, code 75898, Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, is reported only once per operative field per session. Multiple vessels embolized in the same extremity are considered a single field. Code 75898 is used to report follow-up angiograms as necessary to document a satisfac-
tory endpoint of therapy once the embolization procedure has ended.

It would be appropriate to report code 75898 more than once on the same day of service, when more than one operative field is treated or when separate angiograms (performed at different sessions) are necessary to document a satisfactory endpoint of therapy. Modifier 59, Distinct procedural service, must be appended to diagnostic angiography codes when reported in conjunction with a therapeutic radiological supervision and interpretation code on the same date of service.

To illustrate, code 75898 may be reported twice (with modifier 59 appended) when postembolization angiograms are performed on two distinct operative fields at the same session (eg, bilateral renal cell carcinomas; multiple sites of trauma).

Can CPT 36140 can be used for pullback of the catheter

 Is CPT code 36140 assigned for the pullback of the catheter from the contralateral common femoral artery into the ipsilateral common femoral artery for extremity imaging?

Answer: 
No additional code (eg, 36140) should be reported for the pullback positioning of the catheter in this setting.
Code 36246 (second order catheterization) should be the only code reported for selective catheterization of the contralateral common femoral artery from an ipsilateral femoral puncture site because the contralateral catheterization includes the work of the nonselective catheter placement (36140).

The Centers for Medicare & Medicaid Services (CMS) supports the reporting of selective and nonselective codes only in the following circumstances: (1) when the selective and nonselective catheterizations are performed through two separate catheters introduced in separate arterial vessels or (2) when the selective and nonselective catheterizations are performed at separate sessions.

National Correct Coding Initiative edits were developed to allow the reporting of the selective and nonselective codes with the use of a modifier when appropriate for these unusual circumstances.
The rationale for not coding 36140 with 36246 is the  same as for doing a thoracic aortogram and then pulling the catheter back to do an abdominal aortogram. The work of placing the catheter in the second order selective position includes the work of the initial nonselective catheter placement.

If the contralateral leg and the aorta were not studied, then 36140 would be the appropriate code for the ipsilateral angiogram provided a nonselective aortic cannulation was not performed.

CPT code for PTA in external iliac and common femoral artery on the same side

Question: Which angioplasty codes should be reported when percutaneous transluminal angioplasty is performed in the external iliac artery and the common femoral artery on the same side during the same session?

Answer:
The external iliac and common femoral arteries are separate vessels. Any necessary angioplasty within a
single vessel is reported with only one procedural angioplasty and one radiological supervision and interpretation angioplasty code. If there are distinctly separate lesions in the external iliac artery and in the common femoral artery segments, and each is separately treated, both would be coded. Therefore, code 35473, Transluminal balloon angioplasty, percutaneous; iliac, should be reported in addition to
code 75962, Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation, for the external iliac therapy. For the common femoral angioplasty, code 35474, Transluminal balloon angioplasty, percutaneous; femoral-popliteal, should be reported in addition to code 75964, Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and interpretation
(List separately in addition to code for primary procedure).

If angioplasty is performed through an already established access (for a preceding diagnostic or therapeutic procedure), the selective catheterization code should be reported only once. If new or additional access is required, this new additional catheterization (eg, 36140-36247) should be reported in addition to the angioplasty procedure performed.

Angioplasty is generally reported only once per vessel treated. If there are multiple lesions treated within a
single vessel, all of which are treated with angioplasty, only one angioplasty code is reported. Additionally, if
there is one contiguous lesion that bridges more than one vessel, treated with angioplasty, this is considered one angioplasty service and only one angioplasty code is reported. In this case, one would code for the vessel that is dominantly involved and treated. If there are distinct lesions found in two distinct arteries and each lesion is treated separately with transluminal balloon angioplasty, each procedure is separately reportable (eg, superficial femoral and popliteal arteries).

If a second angioplasty is performed in a separate arterial vessel, the radiological supervision and interpretation for the second angioplasty is reported with add-on code 75964.

CPT for Bupivacaine injection for pain management

if a surgical arthroscopy of the knee is performed and withdrawal of the scope. The surgeon then injects bivipacaine for postoperative pain management directly into the knee joint, may code 20610 be
reported in addition to the CPT code for the specific arthro-
scopic procedure performed?

Answer : Code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa), should not be reported when performed concurrent with another intra-articular procedure (eg, knee arthroscopy). However, should the bupivacaine injection be performed at an anatomic site other than that of the knee arthroscopy, then the appropriate code from the 20600-20610 series should be reported, as appropriate, with modifier 59, Distinct procedural service, appended.

How to code for anesthesia for preoperative femoral nerve block for pain control just prior to general anesthesia

Question: If an anesthesiologist performs a preoperative femoral nerve block for pain control just prior to general anesthesia, is this injection inclusive of the overall procedure?

Answer: 
It is appropriate to report pain management procedures, including the insertion of an epidural
catheter or the performance of a nerve block, for postoperative analgesia separately from the administration
of a general anesthetic. management directly into the knee joint, may code 20610 be reported in addition to the CPT code for the specific arthroscopic procedure performed?

When general anesthesia is administered and these injections are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. Whether the block procedure (insertion of catheter; injection of narcotic or local anesthetic agent) occurs preoperatively, postoperatively, or during the procedure is immaterial.

As long as the pain block procedure is intended to serve as a postoperative analgesia regimen and is not the primary anesthetic for the surgical procedure (ie, the general or spinal anesthetic required and employed during the intraoperative event), then it is appropriate to report it separately. As the block is separate and distinct from the anesthesia work, one should append modifier 59, Distinct procedural service, to the injection procedure code.

CPT codes for allergy injections

Allergy injections are reported using CPT codes 95115 for a single injection and 95117 for two or more injections. These codes describe the administration (injection) of the allergenic extract when the extract provision or preparation of the extract is not included in the code descriptor. They do not include the provision or preparation of the extract. Codes 95115 and 95117 are intended to be reported one time, regardless of the number of injections administered. These services are typically performed
by a nurse and do not include physician work. If the physician performs an evaluation and management (E/M) service on the same day as an injection, the physician should document the service and report the appropriate level E/M service code. In cases when there is no physician history or exam performed but the nurse must consult with the physician as to whether the patient should receive the injection and whether dosage adjustments are required (eg, the patient is ill or reports a reaction to the last injection), CPT code 99211 would be appropriate.

CPT 20670

Question: I reported CPT code 21453, Closed treatment of mandibular fracture with interdental fixation, for a closed treatment of mandibular fracture with interdental fixation using arch bars. I am unable to locate a specific code for arch bar removal. Can I report CPT code 20670, Removal of implant; superficial, (eg, buried wire, pin or rod) (separate procedure), for the subsequent removal of the arch bars? Or is there a more appropriate code that I should report?

Answer: It is appropriate to report code 20670 for arch bar removal because it is not considered an inclusive compo-nent of code 21453. Third-party payers may require that a modifier (eg, 58 or
78) be appended to code 21453 if the removal is per-formed within the global period of the initial surgery

What is the CPT code for reexcision of lumpectomy along with sentinel node biopsy

The patient had a re-excision of her lumpectomy site along with a sentinel node biopsy. The physician removed two lymph nodes through an axillary incision. The procedure report notes that the lumpectomy cavity was opened and the entire inferior margin was excised from the anterior surface of the lumpectomy cavity to the posterior. Is it appropriate to report the re-excision with code 19302, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy? Also,
if no lymph nodes were excised and only a re-excision of the lumpectomy site was performed, is it appropriate to report code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy,
quadrantectomy, segmentectomy)?

Answer: 

The re-excision of breast tissue is reported with code 19301. Codes 38500, Biopsy or excision

of lymph node(s); open, superficial, and 38525, Biopsy or excision of lymph node(s); open, deep axillary node(s), may be reported for the sentinel node excision, as appro-priate. If the two nodes are superficial axillary nodes, code 38500 is reported. If the two nodes are deep axillary nodes, code 38525 is reported. If the surgeon performs an injection procedure for node identification, code 38792 is

also reported.

Additionally, because the procedure is clinically likely to occur within the usual postoperative period, modifier 58 should be appended to indicate that this is a related proce-dure by the same physician during the postoperative peri-od. It would not be appropriate to report code 19302 because the sentinel node biopsy is not an “axillary lym-phadenectomy” (ie, not an axillary node dissection).

What is the CPT code for injection through tympanic membrane into ear space

 The patient was injected with gentamycin transtym-panically through the anterior tympanic membrane of the mid-dle ear space. She was placed in the nose up position for 20 minutes and discharged without incident. Does code 69801, Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); tran-scanal, appropriately describe this procedure?

Answer: 
Yes, code 69801 is the appropriate code to report. The transtympanic perfusion of drugs procedure is a
nonexcisional destructive procedure of the labyrinth in which vestibuloactive drugs are perfused transtympanical-ly. Code 69801 includes all instillations that occur during the surgical period as well as evaluation and management services. Diagnostic tests such as audiograms to monitor hearing are not included. Typically, multiple instillations are done over several weeks, eg, three days in succession
then weekly for three to four additional weeks. Sometimes this is done with a needle through the (anesthetized) eardrum, others use a special device in the drum, and others insert a tube and place the ear drug through its lumen.

Q

CPT code for injection of botulinum toxin into a unilateral lumbar paravertebral facet joint nerve

What is the appropriate code to report an injection of botulinum toxin into a unilateral lumbar paravertebral facet joint nerve? The April 2001 CPT Assistant states that chemodenervation with botulinum is different than destruction of nerves because the effect is largely reversible.

Answer: 
Currently, there is no specific CPT code for injec-tion of botulinum toxin into a paravertebral facet joint.
Botulinum toxin acts on the neuromuscular junction and is typically injected into muscles for spasticity or dystonia. Therefore, botulinum toxin injected into the paravertebral facet joint should be reported using the unlisted code 64999, Unlisted procedure, nervous system, becausechemodenervation is not being performed.

CPT for tumor resection of bladder by cystoscopy

Should a 0.2-cm tumor resection of the bladder per-formed through cystoscopy be reported with code 52224, Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy, or 52234, Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)? Should the resection of a 1.0-cm lesion be reported with code 52224 or 52234? Please explain the difference between lesion and tumor with respect to these codes.

Answer: 
Bladder tumors are reported by size. Lesion or tumor terminology is a matter of semantics because the terms are used interchangeably. CPT code 52224 is report- ed for lesions smaller than 0.5 cm. CPT code 52234 is reported for lesions from 0.5 cm to 2.0 cm. Therefore, CPT code 52224 should be reported for the 0.2-cm tumor resection of the bladder performed through cystoscopy and CPT code 52234 should be reported for the 1.0 cm lesion resection performed through cystoscopy.

CPT® Assistant December 2007 / Volume 17 Issue 12

CPT for closed treatment of mandibular fracture with interdental fixation

I reported CPT code 21453, Closed treatment of mandibular fracture with interdental fixation, for a closed
treatment of mandibular fracture with interdental fixation using arch bars. I am unable to locate a specific code for arch bar removal. Can I report CPT code 20670, Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure), for the subsequent removal of the arch bars? Or is there a more appropriate code that I should report?

Answer: It is appropriate to report code 20670 for arch bar removal. Third-party payers may require that a modifier (eg, 58 or 78) be appended to code 20670 if the removal is performed within the global period of the initial surgery by the same surgeon. Therefore, you may wish to check with your local third-party payer to determine its specific reporting requirements.

CPT for pushing food bolus during EGD

Is it appropriate to report CPT code 43247, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body, when an esophagogastro-duodenoscopy (EGD) is performed on a patient who has a food bolus in the esophagus and the physician pushes the bolus into the stomach?

Answer: CPT code 43247 would be appropriate to describe the procedure used in this scenario in which the endo- scope is inserted to the level of the distal esophagus where a foreign body (eg, meat bolus) obstructs further advance-ment. A snare or retrieval device is used to dislodge the bolus, either by removing the bolus intact or fragmenting the bolus and displacing it into the stomach. The scope is reinserted or advanced into the stomach and duodenum to complete the evaluation with particular attention to the gastroesophageal junction. Therefore, it is appropriate to report CPT code 43247 if the food bolus is advanced into the stomach and observation of the stomach and small bowel are included.

What is the appropriate code to report a skin-sparing mastectomy

What is the appropriate code to report a skin-sparing mastectomy? How is the work of sparing the nipple reflected?

Answer: When the physician describes a skin-sparing mas-tectomy, he or she is performing a subcutaneous mastecto-my, CPT code 19304, Mastectomy, subcutaneous, to remove the breast but spare the skin. The nipple sparing has to do with the location of the tumor and whether it is far enough away from the nipple and does not change the subcutaneous dissection performed. Sparing the nipple is sometimes difficult because an inadequate blood supply may lead to its future loss. If the surgeon believes more work is required to spare the nipple, modifier 22, Increased procedural services, may be appended with submission of an operative report to document the extra work involved

CPT Code for Therapeutic Temporomandibular Joint Manipulation

CPT code 21073 was added in CPT 2008 to report thera-peutic temporomandibular joint manipulation and requires the use of general or monitored anesthesia care. Because diagnostic manipulation can also be provided for the tem-poromandibular joint, a differentiation has been designat-ed for this procedure, adding the word therapeutic to the descriptor to differentiate use of this code from those for diagnostic purposes.

21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia
service (ie, general or monitored anesthesia care)

CPT Spinal Osteotomy Codes for Posterior or Posterolateral Approach, Three Columns

Three-column spinal osteotomy procedures are reported when a portion(s) of the vertebral segment(s) from
each of three columns is cut and removed in preparation for realigning the spine as part of a spinal deformity
correction. The three columns are defined as anterior (anterior two-thirds of the vertebral body), middle (poste- rior third of the vertebral body and the pedicle), and pos-terior (articular facets, lamina, and spinous process).

Three-column osteotomy is performed in the thoracic and lumbar regions for the correction of complex spinal defor-mities, such as ankylosing spondylitis, scoliosis, and neuro-muscular scoliosis. Existing codes 22210-22216 also describe posterior or posterolateral osteotomy procedures; however, they involve only one column of the spine. Separate codes for three-column osteotomy are needed to
describe the additional time and risk involved in perform-ing these procedures. A three-column osteotomy permits a greater correction and realignment of the spine than a one-column osteotomy and is indicated for larger, more complex spinal deformities. The unit of service in codes 22206-22208 is one vertebral segment.
Code 22206 is reported for three-column osteotomy when performed in the thoracic region of the spine.

Code 22207 is reported when this procedure is performed in the lumbar region.

Code 22208 is an add-on code and is reported for each additional vertebral segment with 22206 or 22207,
depending on which region is involved.

CPT Codes for Computer Navigation for Musculoskeletal Procedures

CPT has three add-on codes (20985, 20986, and 20987) to report computer navigation for muscu-
loskeletal procedures. The new codes are differentiated by lack of reliance on an image (20985) and for image- based guidance whether the image is obtrained preopera- tively (20987) or intraoperatively (20986). Codes 20986 and 20987 are followed by instructional parenthetical notes that indicate that these codes are reported one time only, regardless of the number of imaging modalities used to obtain the navigation information. Stereotactic com- puter-assisted navigation of the spine is reported with code
61795. Intraopera-tive imaging is not reported separately.

✚20985 Computer-assisted surgical navigational proce-dure for musculoskeletal procedures; image-
less (List separately in addition to code for pri-mary procedure)

✚20986 with image guidance based on intraoper-atively obtained images (eg, fluoroscopy, ultrasound) (List separately in addition to code for primary procedure)

✚20987 with image guidance based on preoper- ative images (List separately in addition
to code for primary procedure)

CPT Modifier 51 exempt codes

Modifier 51 exempt codes are typically adjunctive or reported with other procedures. The amount of pre- and postservice time associated with these codes is minimal, and use of modifier 51 to signify a value reduction would be inappropriate. For information on service time and work relative values, please refer to the AMA publication Medicare RBRVS: The Physicians’ Guide. Multiple codes [eg, 20660, Application of cranial tongs, caliper, or stereotac- tic frame, including removal (separate procedure)] were
removed from the list of modifier 51 exempt codes found in Appendix E of CPT 2008.

The bone graft for spinal surgery codes 20930, 20931, and 20936-20938 have been removed from the modifier 51 exemption list (Appendix E), assigned add-on code status, and relocated to the add-on code list (Appendix D of the CPT codebook).

The CPT Editorial Panel supported the AMA’s RVS Update Committee (RUC) finding that codes 20930-20938 include more characteristics associated with add-on codes rather than modifier 51 exempt codes.
Add-on codes are always performed with a defined base code or codes, whereas modifier 51 exempt codes are not always adjunctive; and the base codes associated with modifier 51 exempt codes are either too extensive to list or not easily defined. Both add-on and modifier 51 exempt codes are similar in that neither should be subject to mul-tiple procedure reductions.

CPT 20555

A 40-year-old male has a painful mass in the anterior thigh. Magnetic resonance imaging confirms a 12-cm
infiltrative mass in the anterior compartment of the thigh. Incisional biopsy reveals a high-grade liposarcoma.
Following wide surgical resection of the mass, catheters are implanted throughout and surrounding the tumor bed for subsequent afterloading brachytherapy. What is the CPT code for the procedure done?

Ans: 20555

Catheterization of the Access Vessel During Endovascular Procedures

Question:

How do I code for catheterization of the access vessel, for example the common femoral artery? Do I bill the nonselective catheterization code 36140?

Answer:

Access to the common femoral artery to perform an angiogram, angioplasty , stent, etc, is not separately reported if the catheter is moved out of that access vessel. For example, if the right common femoral artery is accessed and the end point of the catheter is in the left (contralateral) superficial femoral artery, this is reported as a third order selective catheterization, 36247. The nonselective code is bundled into the selective catheterization.  If the right common femoral artery is accessed and the right superficial femoral artery is the end point of the catheter, this is reported as a first order selective catheterization, 36245.  Remember, selective catheterizations are coded based on the documented end point of the catheter. Documentation of the access vessel (puncture site) is important because it determines what catheterization code to report. The non-selective catheterization code, 36140, is reported only if the catheter is placed in the common femoral artery and not moved from that location. For example, if the catheter is placed in the right common femoral artery and a right extremity angiogram is performed with the catheter remaining in the common femoral artery, 36140 is reported as the catheterization code.

Femoral and popliteal angioplasty in the same leg

How do I bill for a femoral and popliteal angioplasty in the same leg? The CPT code says “femoral-popliteal”, does that mean I can only report 35474 once?

Answer:

That depends!  If the lesion treated is a short, continuous lesion briding both vessels, a single code (35474) would be reported.  If however, angioplasties are performed on two separate and distinct lesions, for example, proximal superficial femoral and distal popliteal lesions, report 35474, and 35474-59, to indicate that two separate lesions in two separate vessels were treated.  Documentation should support the diagnostic findings and the separate location of each lesion treated. In August 2006 CPT Assistant stated “Since the inception of component coding for interventional radiology procedures, the femoral and popliteal arteries have been considered two distinct vessels. If there are distinct lesions found in both the femoral and popliteal arteries and each lesion is treated separately with transluminal balloon angioplasty, CPT code 35474 would be reported twice”.

CPT 49000

I currently provide anterior exposure for spine surgeons doing an anterior lumbar interbody fusion ( ALIF) and have been coding 49000 for an exploratory laparotomy (49010 if the approach is retroperitoneal). Is this correct?

Answer:

Each open surgical procedure is valued to include the approach, the repair and the closure. When providing exposure for a spine surgeon to gain access to the anterior lumbar spine, the vascular or general surgeon is providing the approach (and usually the closure) of the open spine procedure. The spine surgeon performs the repair. Each surgeon is providing a distinct part of a single CPT code (22558), which makes this co surgery per CPT rules. Both surgeons report 22558 with a 62 modifier and each must dictate their own operative note. Reporting an exploratory laparotomy code would be double billing the approach, which is inclusive to the 22558 code.

Billing Medicare for HIVAMAT

I was at a meeting recently and a company representative told me I could bill Medicare for HIVAMAT therapy for swelling and pain reduction for a wide variety of patient conditions. He referenced a CMS transmittal that says the therapy using this device is billed as 91740. It sounds good but I’m skeptical.

Answer:

You are right to be skeptical. The CMS transmittal referenced does not mention that "HIVAMAT therapy is considered manual therapy (which is billed as 91740)" as stated in the billing information you were given. In fact, 91740 is mentioned only incidentally in this August 3, 2006 transmittal as part of a CMS discussion on how to bill timed therapy codes.  

Per CPT, 91740 involves:  

CPT code 97140, Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, was added to CPT in 1999 to accurately report manual (soft tissue and joint) techniques. Manual therapy techniques include, but are not limited to: connective tissue massage, joint mobilization and manipulation, manual lymphatic drainage, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. As the code descriptor states "manual," providers use their hands to administer these techniques. Therefore, code 97140 describes "hands-on" therapy techniques.

HIVAMAT, as described in its consumer literature, is a pulsed electrostatic energy therapy combined with an oil-based massage. Based on the video of the product's use, the massage is minimal and probably would not meet the definition of "therapeutic" massage.

62 modifier spinal surgery

I performed the exposure for a spine surgeon doing an anterior lumbar spine procedure. I know I report the spine code with a 62 modifier, as will the spine surgeon.  (See the Coding Coach from earlier this year) He performed 2 levels. Can I report the additional levels?

Answer:

According to CPT, each surgeon would report the code for the initial level and any add-on codes with the 62 modifier (indicating co-surgery). So if this was a two level anterior lumbar interbody fusion, the codes for each surgeon would be:

Vascular/general surgeon

22558-62 first level

22585-62 additional level

Spine surgeon                                                 

22558-62 first level                                        

22585-62 additional level    

laparoscopic cholecystectomy aborted due to infectious process

Our surgeon planned for a patient to have a laparoscopic cholecystectomy. Following exploration of the area in the OR, the surgeon aborted due to significant infectious process. We reported the cholecystectomy code with a modifier 53. The patient returned to the OR this week, and we are wondering if we should use modifier 78 or 58.   What recommendation do you have?

Answer:

If the case was aborted after the exploratory part of the procedure, report the laparoscopic exploration code, 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).  For the second procedure, which we assume by your question is occurring within the global period of the exploratory laparoscopy, append modifier 58 to the appropriate cholecystectomy CPT code to indicate a return to the OR for a planned/related procedure.

Use modifier 53 when the surgical procedure is aborted related to life-threatening complications.  

fem-pop bypass with vein and an endarterectomy

I performed a fem-pop bypass with vein and also did an endarterectomy of a severely stenosed common femoral artery.  Shouldn’t I report both procedures?

Answer:

Per CPT, “primary vascular procedures include establishing inflow and outflow by whatever procedures necessary.”  Excising plaque for a diseased vessel contiguous to the bypass is considered bundled into the bypass and not separately reportable.

fine needle aspirations in the office

Our new surgeon is performing fine needle aspirations in the office and wants to bill for the use of the ultrasound machine. The practice owns the machine.  Is this a separately reportable service, and if yes, how do we report this?

Answer:

Yes, the service is separately reportable. The key to reporting lies in your statement that you own the equipment as this allows the practice to report the “global” radiology code.

Let’s take a look at CPT® code 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.  CPT®code 76942 without any modifiers appended is considered a global radiology code. Medicare will consider payment for radiology codes if the service is reported as a global code (without modifiers), or if the service is reported with a professional component modifier 26 for the professional interpretation, or if there is a TC modifier indicating the technical component only.

In the grid that follows, you see that payment for the global code is 5.04 RVUs.  Medicare pays the global code when the physician performs the service in the office setting and provides the professional interpretation.  In your scenario, the global payment would apply because the office owns the technology and the physician is using the technology to perform the aspiration.

Removal of gastrostomy

Is there a CPT code for the removal of a gastrostomy tube?

Answer:

There is not a specific code for the removal of a gastrostomy code.   Let’s look at a couple of scenarios.

In the office, during the global period—report 99024

In the office, outside the global period, report 9921x

If the patient is returned to the OR and the tube is removed and the gastrostomy site is surgically closed, report 43870, Closure of gastrostomy, surgical.

CPT 36145

I see the 36145 is no longer in the CPT book. What do we use in its place for placing a catheter in an AV shunt for imaging and/or interventions?

Answer:

CPT deleted 36145, introduction of a needle or catheter arteriovenous (AV) shunt created for dialysis. In its place, CPT has established two new codes, 36147 and 36148.  36147 is reported for the first catheter access of the AV shunt and includes all fluoroscopy (previously reported as 75790, angiography AV shunt). 36148 is reported for an additional catheter access for a therapeutic intervention. 75790 has also been deleted since it is now inclusive to 36147.

Removal of infected catheters

 The surgeon documented that she removed an infected infusaport. Is this reportable with a CPT code or is it bundled in the E&M service.

Answer:

The correct code for the removal of a catheter with a port or pump is CPT code  36590 (Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion).   Most of the tunneled insertion codes have a ten day global period. So you will append modifier 78 for the removal, if the patient was returned to the OR during the ten day global period. If the return to the OR was outside the ten day global period, then you do not need modifier 78.  CPT code 36590 has a ten day global period, thus if you are not in the global period of an associated procedure, you will start a new ten day global period again related to the removal procedure. 

Catheter to dislodge the clot

I had a patient with a clotted forearm AV shunt. I used a catheter to dislodge the clot and then injected a bolus of tPA. Can I report the thrombectomy (36870) and the tPA injection?

Answer:

36870, thrombectomy of an AV fistula, includes all mechanical and pharmacological methods employed to dissolve or dislodge the clot. The thrombolytic injection is an inclusive component of 36870 and cannot be reported separately

How to report the use of a vascular closure device

How do I report the use of a vascular closure device, such as an angioseal, placed into the arterial or venous site after an intervention?

Answer:

There is no CPT code for the placement of a vascular closure device.  This is considered inclusive to the interventional procedure. Medicare has established a G code (G0269) for recording this activity, however it’s payment status in the Medicare physician’s fee schedule is as a bundled service and not separately payable.

Repair of an initial inguinal hernia and also strangulated initial hernia

Our surgeon reported CPT codes 49505 and 49507 for repair of an initial inguinal hernia on the right and a strangulated initial hernia on the left. We put a modifier 51 on the second code, but the payor denied the service as bundled.  Is this correct?

Answer:

No, it is not a correct denial. We recommend using modifier 59 instead of modifier 51 to indicate distinct separate services. The payor may think you attempted to reduce the hernia, it became strangulated, and you are trying to report two services for the same site.  If the physician’s documentation supports both services, append a modifier 59 to CPT code 49505, repair reducible, initial hernia. It is correct to report both services, however Medicare has a CCI edit in place on this code combination. Append modifier 59 indicating that the repair of the incarcerated hernia was performed on the left, and the reducible hernia was on the right side.

TPA

As part of a percutaneous thrombectomy, I injected a bolus of tPA. Can I bill 37201 for the thrombolysis?

Answer:

No.  Per CPT, intraprocedural injection (s) of a thrombolytic agent is included in a percutaneous thrombectomoy and not separately reportable.  37201, continuous infusion of thrombolytic drugs, is reportable for a subsequent or prior infusion of a thrombolytic agent. A continuous infusion means that the thrombolytic is infused through a catheter over several minutes. A bolus injection of tPA is an inclusive part of a thrombectomy and not separately reportable.

Surgeons as assistant

We work with several surgeons as assistants.   When our surgeon is the assistant, we report the CPT codes with a modifier 80. Do we enter into the associated global period (typically 90 days)?  Our surgeon does not see the patient during the post operative period–should he?

Answer:

This is a great question. An assistant surgeon is reimbursed for assisting on the intra-service portion of a procedure. As such, the assistant surgeon does not have a global period.   Since you are in a different group practice, your surgeon does not have a global period assigned to their work related to the service they functioned as an assistant surgeon.  There is no need for your surgeon to perform “postoperative services” as the reimbursement for the assistant does not include any postoperative care. 

Single incision surgery

Our surgeon began performing “single incision surgery,” and she wants to know if we should report this with an unlisted CPT code or if adding a modifier 22 to the CPT code is correct.  As an example, the surgeon just dictated this as a laparoscopic choleyctectomy procedure.

Answer:

 The number of incisions and the length of the incisions do not affect the coding of the case.  For example, MIS, or Minimal Incision Surgery has been around for many years, and the smaller incisions do not change the reporting of the procedure.  In your scenario, report the appropriate cholecystectomy code. Do not append a modifier 22, unless there were other extenuating circumstances that significantly increased the complexity of the procedure.

Non-Physician Provider billing

Our general surgeon recently employed a nurse practitioner in the office. The nurse practitioner is seeing patients on rounds in the hospital, and she recently submitted a charge for a 99232 on a Medicare patient who was post-op total thyroidectomy. The documentation for the visit all pertained to the thyroidecotmy. Can she report this E&M service when the patient is in a global period? She says yes, because she did not assist and is not in a global period.

Answer:

Great question and one of increasing concern as it relates to one of many issues related to Non-Physician Provider billing. We appreciate your attentiveness and raising the question.  While the nurse practitioner was not involved in the surgery, she is employed by the surgeon who performed the surgery; thus all visits related to the surgical procedure are included in the global period, and not reportable whether performed by the surgeon or the nurse practitioner. If the visit was for an unrelated problem that was evaluated and managed, the service would be reportable by the surgeon or the nurse practitioner, and a modifier 24 would be appended to the E&M and the appropriate unrelated diagnosis linked to the E&M.

Excision of a neuroma

Our surgeon has been treating a patient with chronic post-operative pain from an inguinal hernia repair two years ago.   She is planning to take the patient to the OR for the excision of a neuroma.  We need to precertify the case and are unsure what code we should use. 

Answer:

Without more specific information, we cannot identify a specific code.  However, we can suggest a code range to review for the excision of a neuroma. Report the appropriate code based on the documentation of excision and anatomic location. 

64774		Excision of neuroma; cutaneous nerve, surgically identifiable
64784		major peripheral nerve, except sciatic
64786		sciatic nerve
64788		Excision of neurofibroma or neurolemmoma; cutaneous nerve

Complex closure for a procedure

A surgeon performed a complex closure for a procedure defined by one of the new soft tissue tumor codes found in the Musculoskeletal section of the CPT book.  Our surgeon stated that she was heard that we could report a complex closure in addition to the surgical resection.   We would like to verify if this is indeed true, and if so, does that mean any surgical procedure that requires complicated closure be billed separately. 

Answer:

The new and revised soft tissue tumor codes brought with them very specific coding guidelines applicable to these codes only.   According to CPT 2010,”Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which may be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision.”

According to this definition, if a complex closure is required and is performed for reasons other than closure secondary to elevation of the tissue planes, the complex closure may be reported in addition to the surgical procedure.

Laproscopic procedure to open procedure

A surgeon began a laparoscopic procedure and after lysis of dense adhesions had to convert to an open Hartmann procedure and open mobilization of the splenic flexure.  How do I report this? 

Answer:

The appropriate CPT codes based on the information provided in your inquiry are:

44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure)

If the surgeon’s documentation indicates significant additional work or time due to the initiation of the procedure laparoscopically and then conversion to an open, the use of  modifier 22, Increased Procedural Service may be warranted.  Add the diagnosis code for conversion of a laparoscopic procedure to an open as the last diagnosis code for each procedure: V64.41 Laparoscopic surgical procedure converted to open procedure.

Removal of a chest wall tumor

Our surgeon removed a chest wall tumor and following the resection documented the following closure: “The wound was irrigated out with saline and closed the deep tissue with 3-0 Dexon, the skin with a mixture of 4-0 nylon, 3-0 silk, and skin staples.” My question is not related to the code for the resection, but is related to the documentation for the closure.  Can you advise if the previous documentation supports an intermediate or complex closure? Is this an intermediate or complex closure?

Answer:

There is no documentation of tissue undermining or advancement of skin to achieve the closure, thus it appears based on this documentation alone, it is an intermediate repair.  Intermediate repairs are included in the closure of the new soft tissue musculoskeletal codes, thus based on the documentation provided, the repair is inclusive and not separately reportable.

Removal of infected mesh

A surgeon took a patient to the OR and removed infected mesh at the site of a previous incisional hernia repair.  The patient has been treated for chronic infection and drainage and extensive wound care.  I have searched and am not able to find a CPT code.  Is there a CPT code for removal of infected mesh?

Answer:

CPT code 11008 (Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure)) was revised in 2008 to include the removal of infected mesh for chronic infection.   CPT code 11008 is an add-on code, thus is reported in addition to another procedure at the same setting.

Placement of a jejunostomy tube for tube feeding purpose

 A patient underwent placement of  a jejunostomy tube for tube feeding purposes?

Answer:

The answer to this question depends how the tube was placed.  Review the operative note and then look at CPT code 44300 (Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate procedure)) if performed as an open procedure.   While the code does not specifically state “jejunostomy” the generic “enterostomy” description applies to the jejunostomy.

If the surgeon placed the jejunostomy tube percutaneously with fluoroscopic guidance, look at CPT code 44941, Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.  Image guidance is not separately reportable as it is included in CPT code 44941, but the code requires documentation of the image and a separate report.

Drainage of a seroma and drain placement

A patient returned a patient to the OR for the drainage of a seroma and drain placement two weeks post-op of a femoral bypass surgery.  What are the codes for the seroma and drain placement?

Answer

There is no CPT code for the placement of the drain associated with the seroma drainage.

Look at CPT code 10140, Incision and drainage of hematoma, seroma or fluid collection as a code option based on the surgeon’s documentation.  The placement of the drain is inherent to the drainage procedure and not separately reportable.

Append modifier 78 to the appropriate surgical procedure as the patient is in the global period of the bypass surgery.