Questions and Answers
Evaluation and Management (E/M) Services: Hospital Inpatient and Observation Care Services
Question: A female patient was seen in the emergency department (ED) where it was deemed appropriate to have her admitted as an inpatient. The admitting physician then requested a neurological consultation. The neurologist saw the patient the next day and performed a high-level medical decision making consultation on the patient. Based on the information provided, which of the following code(s) should the neurologist report: the initial hospital inpatient or observation care code (99223), the subsequent hospital inpatient or observation care code (99233), or a consultation code (99252-99255)?
Answer: The neurologist may report the initial hospital inpatient or observation care code 99223. When a patient is admitted as an inpatient by another physician who requested the consultation, the consultant may report the initial hospital inpatient or observation care code, instead of a consultation code.
Surgery: Integumentary System
Question: Are Current Procedural Terminology (CPT) add-on codes 15853 and 15854 intended as physician practice–based codes, or may they be reported in both physician and hospital/facility settings?
Answer: New codes 15853 and 15854 are intended for reporting practice expense (PE) related to suture or staple removal when not inherent to a procedure code (0-day global codes). For non-facility settings (eg, office, home), these codes may only be reported in conjunction with an office visit E/M code to account for the additional PE related to the suture or staple removal and not for the work related to the E/M service. For 10-day and 90-day global codes, if the suture or staple removal were performed by a different physician who is not in the same group, then the related PE would be included only in the payment for transferred postoperative care using modifier 55, Postoperative Management Only. Therefore, these two new codes are intended for PE in non-facility settings only.
Surgery: Musculoskeletal System
Question: Is it appropriate to separately report the repair of the interphalangeal joint collateral ligament (26540) when performed on the same joint as an interphalangeal joint arthroplasty with implant (26536)? The radial collateral ligament was previously disrupted, and the ulnar collateral ligament was released during the procedure. Both were reattached after the permanent implant was placed, along with a volar plate reattachment. Some surgical descriptions of interphalangeal joint arthroplasty procedures describe release of the ligaments to access the joint space, but others say the collateral ligaments are spared.
Answer: No, the only code that is appropriate to report the described procedure would be code 26536, Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man’s land); primary, without free graft, each tendon, because the collateral ligament reattachment is included and would not be reported separately.
Surgery: Respiratory System
Question: Is it appropriate to separately report a nasal endoscopy (31237) performed on a patient seen 2 months post-operatively following a septoplasty (30520), or would the nasal endoscopy be included in the surgical global period and, therefore, not reportable?
Answer: Although the procedure described by code 30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, was performed and reported previously, endoscopic sinus debridement is not typically required for this procedure and would not be included in the 90-day global period assigned to code 30520. Therefore, endoscopic sinus debridement at the two-month status checkup visit may be reported. This is explained in the “Coding Clarification: Reporting Code 31237 for Endoscopic Sinus Debridement” in the July 2021 issue of CPT Assistant :
Endoscopic debridements of the operative sites performed beyond the code-specific global period are reported with code 31237 and, if bilateral, with modifier 50, Bilateral Procedure, appended. Sinus debridements within the global period of another intranasal procedure that generally does not require debridement, such as septoplasty, may be reported by appending modifier 79, Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period, to code 31237. Documentation associated with the use of code 31237 should include the medical necessity for performing debridement, specific site(s) addressed, type of anesthesia, depth of material debrided with instruments and endoscopes utilized, manner of hemostasis, and use of and/or the type of packing. As with all procedures, complications and any other relevant factors should be included.
Surgery: Cardiovascular System
Question: Which code should be reported when a physician performs an exchange of a tunneled hemodialysis catheter and a balloon angioplasty of fibrin sheath via the same venous access as the tunneled hemodialysis catheter on a patient?
Answer: The most appropriate way to report fibrin sheath disruption associated with a catheter exchange (using the existing tract access for both services) is with code 37799, Unlisted procedure, vascular surgery, to represent the work of the fibrin sheath disruption in addition to the appropriate catheter exchange code (eg, 36581, 77001).
When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.
Surgery: Female Genital System
Question: What is the appropriate code to report laparoscopic ovarian drilling when it is performed during the same session as laser ablation and resection of endometriosis, endometrial sampling, and chromotubation?
Answer: It would be appropriate to report code 58679, Unlisted laparoscopy procedure, oviduct, ovary, for the service described. While code 58662, Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method, may seem appropriate, the service described is not fulguration or excision of lesions—it is drilling into the ovary. Reporting code 58662 misrepresents the nature of the service as ovarian drilling, which is typically performed for infertility treatment and often results in claim denials. The same is true of code 49322, Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple), because in the described service no cavity or cyst is aspirated; it is being drilled, typically performed for infertility treatment purposes. Therefore, the unlisted code is most appropriate.
When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service.
Surgery: Digestive System
Question: Would it be appropriate to report code 15734 for laparoscopic or robotic abdominal wall reconstruction following abdominal hernia repair?
Answer: No, code 15734, Muscle, myocutaneous, or fasciocutaneous flap; trunk, describes an open procedure and may not be reported when performed via a laparoscopic or robotic approach. When laparoscopic or robotic defect closure requires the component separation procedure, it would be appropriate to report code 49659, Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy, in addition to the code for the abdominal hernia repair. When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service.
Question: Is it appropriate to report two units of code 15734 when both retrorectus (posterior) and transverse (anterior) release are performed via an open approach on the same side for abdominal wall reconstruction after hernia repair? What should be reported if the same two rectus releases are performed on both sides?
Answer: Code 15734, Muscle, myocutaneous, or fasciocutaneous flap; trunk, may only be reported once per side for rectus muscle flaps—posterior and anterior releases on the same side are not reported separately. In rare instances, it may be possible to report four units of code 15734 if, for example, both rectus and pectoralis muscle flaps for a sternal defect are reported on both sides. However, this would be a very unusual procedure and even more unusual in relation to abdominal hernia repair. In addition, the bilateral procedure concept does not apply to code 15734; therefore modifier 50, Bilateral Procedure, should not be appended to code 15734 when the procedure is performed on both sides. Instead, append either modifier 51, Multiple Procedures, or 59, Distinct Procedural Service, as determined by applicable individual third-party payer policy.
Surgery: Urinary System
Question: What would be the appropriate code to report a looposcopy procedure involving bilateral retrograde pyelograms and stent placement?
Answer: Looposcopy is endoscopy performed on a section of bowel that functions in place of the urinary bladder. The correct code to report for this procedure is code 52332, Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type), with modifier 50, Bilateral procedure, appended if performed bilaterally. The bladder replacement is considered the same as a native bladder; therefore, cystoscopy procedures are reported the same whether the cystoscopy is performed on a native bladder or a bladder replacement (eg, ileal conduit, neobladder).
It would not be appropriate to report code 50688, Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit, because this procedure does not require the use of cystoscopy because the catheter is outside the body. Code 50688 would be the correct code to report only if the stent or catheter were externally accessible.
Another code that may cause confusion is code 50385, Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation, which is typically reported for a procedure performed by an interventional radiologist, who places a snare into the bladder and then grabs the stent and replaces it with the aid of fluoroscopy, often under anesthesia.
Pathology and Laboratory: Surgical Pathology
Question: Surgical pathology examination of lipoma is reported using code 88304. However, would an angiolipoma biopsy be reported as a biopsy of a different disease or subset of lipoma?
Answer: The Surgical Pathology subsection guidelines in the CPT code set state that any unlisted specimen should be assigned to the code that most closely reflects the physician work involved when compared to other specimens assigned to that code.
Because lipoma in or of soft tissues is included in code 88304, Level III – Surgical pathology, gross and microscopic examination, this code would be the most appropriate to report when performing surgical pathology that includes gross and microscopic examination. It would not be appropriate to report code 88305, Level IV – Surgical pathology, gross and microscopic examination, because lipoma is specifically listed as one of the excluded items in the exclusion (“other than”) list.
Reference : 2023 July CPT assistant from AMA