Below are the Question and Answers for the released August 2023 CPT assistant edition.
Questions and Answers
Evaluation and Management (E/M) Guidelines
Question: When is the conversation between an emergency room (ER) physician and the admitting physician counted as an element in medical decision making (MDM) from the perspective of the ER physician?
Answer: In the “Amount and/or Complexity of Data to be Reviewed and Analyzed” section of the E/M guidelines, the definition of discussion states that the discussion is included only when it is used in the MDM of the encounter. Determination of whether a conversation between physicians may be applied toward MDM by the ER physician depends on whether the conversation has met the above criteria.
If the conversation is required to determine the next steps in how the patient will be treated (eg, admission, outpatient visit, additional testing/imaging), the ER physician may count the conversation as a data element for MDM when determining final E/M code selection for the ER encounter.
Alternatively, if the conversation between physicians was solely administrative (eg, notification of consult request) and was not used in the MDM of the ER physician when determining next steps in the patient’s care, the discussion may not be considered when determining the appropriate MDM level.
Read also: E/M Coding guidelines changes for coders
Surgery/Integumentary System
Question: What would be the appropriate Current Procedural Terminology (CPT) codes to report a repair for multiple lacerations requiring a 3.5-cm intermediate repair of the upper arm, an 8.9-cm simple repair of the forehead, and a 2.1-cm intermediate repair of the lower leg?
Answer: It would be appropriate to report codes 12032, Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm, and 12015, Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm. Per CPT guidelines, sum the length of repairs for each group of anatomic sites performed with the same type of repair (eg, intermediate vs simple). The codes should be sequenced from the most complex to the least complex; in this example, sequencing the intermediate repair first followed by the simple repair. Because both the laceration of the upper arm and the lower leg are both located on the extremities and are described in the same code descriptor, they should be summed for total length of both repairs and reported with code 12032.
Read also: Emergency Department Coding rules for coders
Question: What would be the appropriate codes to report for multiple lacerations requiring a 13.5-cm intermediate repair of the chest, a 1.5-cm intermediate repair of the shoulder, and a 2.5-cm complex repair of the scalp?
Answer: It would be appropriate to report codes 13120, Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm, and 12035, Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm. Per CPT guidelines, sum the length of repairs for each group of anatomic sites performed with the same type of repair (intermediate vs simple). The intermediate laceration of the chest and intermediate laceration of the shoulder are both included in the same list of anatomic sites and therefore summed. The codes are sequenced from the most complex to the least complex, in this example, sequencing the complex repair first followed by the intermediate repair.
Question: A patient presents with a contiguous laceration that extends from the left forehead down and across the left eyelid after an accident. The surgeon debrides the wound edges and performs an intermediate repair. The combined length of the repaired defect is 6 cm, with 4.6 cm on the forehead and 1.4 cm on the eyelid. How would this contiguous laceration repair, which runs over multiple anatomic locations, be reported?
Answer: According to the CPT 2023 code set’s instructions with an example in the Repair (Closure) subsection, “[w]hen multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (eg, face and extremities). Also, do not add together lengths of different classifications (eg, intermediate and complex repairs).”
The coding guidelines also state that “complex repair may be reported when an intermediate repair as well as debridement of wound edges for traumatic lacerations is performed.” Other qualifiers for complex repair include extensive undermining and placement of retention sutures. Based on the coding guidance, the contiguous defect would not affect the code selection because the defects are in different anatomical locations. Therefore, the repairs must be reported with codes that reflect the defect location, the length of the repair, and the technique used to repair each defect.
Hence, the services as described involving debridement of the lacerations followed by intermediate repairs from two anatomic sites would be reported with two codes, one for the more complicated closed repair and the other for the less complicated. (Note that closed repair is the technique indicated in the documentation.) Because the complex repair on the forehead is longer compared to the complex repair on the eyelid, the forehead repair should be listed first and reported with code 13132, Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm, followed by code 13151, Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm, for the eyelid repair.
Read also: CPT coding Quiz for Medical coders
Question: A 45-year-old male presents to the office with biopsy-proven basal cell carcinomas with face lesions of 1.2 cm and 0.7 cm and an arm lesion of 2.4 cm. After discussing management options with the patient, the lesions were treated with cryotherapy. What would be the appropriate codes to report?
Answer: For this scenario, it would be appropriate to report codes 17263, Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm; 17281, Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm; and 17282, Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm.
Surgery/Musculoskeletal System
Question: What code would be reported for replanting an amputated thumb at the mid-proximal phalanx?
Answer: It would be appropriate to report code 20827, Replantation, thumb (includes distal tip to MP joint), complete amputation, for this scenario.
Question: Is there any special consideration given for excision of soft tissue tumors located on digits (ie, fingers and toes)?
Answer: Specific guidelines are provided in the CPT code set for reporting the excision of digital subcutaneous soft tissue tumors (26113, 26116, 28039, 28043) vs excision of digital subfascial soft tissue tumors (26111, 26115, 28041, 28045) because of the thinness of the digits’ subcutaneous layer. Per the Musculoskeletal System section guidelines, “Digital (ie, fingers and toes) subfascial tumors are defined as those tumors involving the tendons, tendon sheaths, or joints of the digit. Tumors which simply abut but do not breach the tendon, tendon sheath, or joint capsule are considered subcutaneous soft tissue tumors.”
Surgery/Respiratory System
Question: A 10-year-old male who was choking on a small latex balloon was rushed to the ER. The balloon was lodged in the trachea just distal to the larynx and threatened to further obstruct his breathing. After administration of topical anesthesia, the balloon was removed from the trachea using biopsy forceps through a flexible fiberoptic laryngoscope. What would be the appropriate CPT code to report?
Answer: For this clinical scenario, report code 31577, Laryngoscopy, flexible; with removal of foreign body(s).
Surgery/Digestive System
Question: What code would be reported for a subtotal pancreatectomy with autologous transplantation of pancreatic islet cells for a patient with type 1 diabetes mellitus?
Answer: It would be appropriate to report code 48160, Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells.
Radiology/Diagnostic Ultrasound
Question: How would a contrast-enhanced ultrasound (CEUS) be reported?
Answer: CEUS is a procedure that uses dynamic microbubble contrast administration with ultrasound imaging to evaluate lesions. For the first lesion, report code 76978, Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion. For each additional lesion, report code 76979, Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection (List separately in addition to code for primary procedure), as needed.
Effective January 1, 2023, bubble-contrast agent (SD332, Bubble contrast) was removed from direct practice expenses; therefore, in addition to reporting the CPT code(s) for CEUS, the supply item would be reported separately with a Healthcare Common Procedure Coding System (HCPCS) Level II supply code (eg, Q9950, Injection, sulfur hexafluoride lipid microspheres, per ml).
Reference: August 2023 CPT assistant from AMA