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.

Modifier 80 vs 82

Question:

What is the difference between modifier 80 and modifier 82 when a physician is acting as an assistant during surgery?

Answer:

While both modifier 80 and modifier 82 are used when a physician is actively participating as an assistant to a primary surgeon during a surgical procedure, modifier 82 is used in teaching or university hospitals that have approved Graduate Medical Education (GME) programs for Residents. In these teaching hospitals, there must be documentation indicating that no qualified resident was available to assist, to allow for another physician to act as the assistant surgeon, and then modifier 82 is appended to that assistant surgeon.

*This response is based on the best information available as of 1/2/25.

Pre-op vs Post-op Diagnosis

Question:

Is there a difference between a pre-operative diagnosis and a post-operative diagnosis?

Answer:

Pre-operative diagnosis is based on the “Reason for the surgery” or the condition affecting the patient leading to the necessity of the surgery. Underlying co-morbidities that can affect the surgical outcome or represent a risk to the patient can also be included but the documentation must support their relationship to the patient risk.

Post-operative diagnoses are based on the findings determined during the surgical procedure.  Post-op diagnosis may be the same as the pre-op diagnosis or may be more definitive.

*This response is based on the best information available as of 12/19/24.

Laparoscopic vs Percutaneous

Question:

What is the difference between laparoscopic and percutaneous procedures, and how do we choose the correct CPT code for these?

Answer:

Laparoscopy refers to a flexible tube (laparoscope) inserted via small incisions, typically in the abdominal or pelvic cavity for direct visualization of the body cavity and organs. These CPT codes will have the term “laparoscopic” in their description.

Percutaneous procedures are minimally invasive procedures performed via a puncture or minor small incision with no direct visualization of structures. They are performed with imaging guidance. These CPT codes will have the term “percutaneous” in their code description.

*This response is based on the best information available as of 12/5/24.

Is Documentation of HPI and Exam Necessary in Determining a level of E/M?

Question:

With the 2021 and 2023 Guideline changes, is it necessary to document an HPI and Exam when neither counts towards the level of service?

Answer:

As described in the most recent AMA E/M guidelines, documentation of a history of present illness (HPI) and an exam are no longer required to contribute to the level of an E/M service. Today, documentation of medical decision-making or time is the sole determinant supporting a level of E/M.  E/M documentation should include a medically appropriate history and examination. While the nature and extent of the history and exam are determined by the clinician, they add to the medical necessity of the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical providers.

*This response is based on the best information available as of 11/14/24.

Use of Robotic Systems During Surgical Procedures

Question:

What is the code for a robotic procedure?

Answer:

When surgical procedures involve the use of robotic surgical systems, the robotic component can be represented by HCPCS code S2900.  However, there is no RVU associated with this code, and it is not reimbursed under the Medicare payment system.   The best practice is to set a fee for the extra physician work involved with robotic assistance, document medical necessity for the use of the robot, and incorporate this code into billing for tracking purposes when used.

*This response is based on the best information available as of 10/31/24.