Discrepancy between Procedure Title and Documentation Details

Question:

If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?

Answer:

CPT codes are always chosen based on the documentation within the detailed portion of an operative record.  If the details within the body of the report do not match the “procedure title” listed in the beginning of the operative report, the provider should be queried for clarification and a possible addendum to the record if necessary.

*This response is based on the best information available as of 1/16/25.

Co-Planing of AC Joint

Question:

Our surgeon documented co-planing of the AC joint/distal clavicle. The diagnosis is bone spurs. Does this work support CPT code 29824, arthroscopic distal claviculectomy?  

Answer:

Thank you for your inquiry. Co-planing of the AC joint/distal clavicle does not support a distal clavicle resection. To report CPT code 29824, the documentation should include that the surgeon performed a “resection of the distal clavicle.” If the surgeon documents the amount, it should be based on the surgeon’s assessment of the amount of bone excised. 

In the early 2000’s the AAOS clarified the amount in the Global Service Data Guide that the amount of distal clavicle resection did have to be 1.0 cm. The AMA published a correction recently saying that the CPT code does not include the requirement of a specific bone-excision measurement of 1.0. This is consistent with the AAOS’s early position that the amount excised must be specific to the patient anatomy, physical size, and other factors. However, co-planing, removal of osteophytes, removal of bone spurs does not support a distal clavicle resection.  

*This response is based on the best information available as of 1/16/25.

Prescription Drug Management

Question:

Every patient I see is in pain, and I discuss prescription medications (primarily prescription NSAIDs, Neurontin, and/or muscle relaxers) with almost every patient. If I document “discussed prescription drug management with Mobic, patient defers and will continue Motrin OTC as needed.” Is this prescription drug management?

Answer:

If this is a true clinical management option for this unique patient based on their history, pain level, the number of times you have seen them, imaging, and the patient is not responding to OTC meds, and you determine Mobic is the best next course of treatment for the patient, and they still decline it, this can support prescription drug management. You are still recommending something that has a risk to the patient. This is from the clinical standpoint, which must be clearly documented in the note.

Be aware, many payors have increased scrutiny in this area and may not see it the same way. It can go both ways, so you must be careful. If you routinely do this for every patient to increase your code level and submit all of these as level fours, you may be at risk and set yourself up for an audit from a payor.

Prescription drug management involves a prescription-strength drug that the patient must go to the pharmacy to get. The name, dosage, strength of the drug, and how to take it, along with any rationale for why it is prescribed at the time of the visit, also need to be documented. Payors want to see this documentation in the plan of care. Prescription drug management involves the risk that you take prescribing and the risk to the patient taking the medication.

Refilling a current prescription does not automatically equate to a Moderate level of MDM. The billing practitioner must document the rationale for continuing the medication for the patient at the visit (e.g., the patient’s pain is well-controlled on x mg at this time, and he/she will continue the current dose).

*This response is based on the best information available as of 1/16/25.

Swimmer’s Ear

Question:

I am new to ENT coding and am not certain what code I should use. The physician placed an oto-wick in the left ear using the microscope on a patient with swimmer’s ear. Do I just report the microscope code 69990 or do I use a different CPT code?

Answer:

There is no specific CPT code for ear wick insertion. Ear wick insertion is considered a component of the evaluation and management (E/M) service. If the physician uses the microscope you may report CPT 92504 (Binocular microscopy) in addition to the E/M service.

*This response is based on the best information available as of 1/16/25.

Donor or recipient site?

Question:

I’m a new plastic surgery coder and still learning. Are muscle flaps coded to the recipient site or coded by the donor site?

Answer:

Thank you for contacting KZA with your question. We understand that this can be confusing. According to CPT guidelines, muscle flap codes are selected based on the donor site.

*This response is based on the best information available as of 1/16/25.

Number and Complexity of Problems Addressed

Question:

I see a number of patients with chronic problems such as dermatitis, psoriasis, history of skin cancer and acne to name a few. What defines stable versus exacerbation or progression?

Answer:

Based on the AMA CPT guidelines a chronic illness is expected to last at least a year or until the death of the patient. You as the practitioner determines when a condition becomes chronic. Of course, there are many conditions that are chronic by the nature of the disease. A stable chronic illness is defined by the specific treatment goals of each individual patient. A patient who is not at treatment goal, not responding to treatment, condition failing to improve, etc. is not stable.

If the patient has a chronic illness with exacerbation, progression or side effect of treatment or inadequately controlled, this would be considered a chronic illness with exacerbation or progression. Typically, a condition exacerbating will require a change or modification in the plan of care. It is important for each problem addressed the practitioner documents the complexity of the problem (stable, chronic, acute, uncomplicated) and the status of the condition (at treatment goal, inadequately controlled, worsening, improving) to paint a clear picture of the condition.

*This response is based on the best information available as of 1/16/25.