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Impatient Consultation Coding for Medicare
If you see a Medicare patient for the first time in the hospital as an inpatient consultation, what code would you bill for the EM?
Question:
If you see a Medicare patient for the first time in the hospital as an inpatient consultation, what code would you bill for the EM?
Answer:
The EM would be reported as an Initial hospital or observational care codes (99221-99223) with the appropriate level based on MDM or Time. Medicare does not allow payment for inpatient consultation codes 99252-99255.
*This response is based on the best information available as of 3/27/25.
Esophageal Sphincter Augmentation for GERD
How is esophageal sphincter augmentation for GERD reported?
Question:
How is esophageal sphincter augmentation for GERD reported?
Answer:
Report CPT code 43284 for laparoscopic placement of the augmentation device (i.e. magnetic band). CPT code 43285 is reported for subsequent removal of the device.
*This response is based on the best information available as of 3/13/25.
Abdominal Hernia Defect Size
Our general surgeon often does not include the size of the abdominal repair in his documentation; can we use the pathology report to determine the correct size for CPT selection?
Question:
Our general surgeon often does not include the size of the abdominal repair in his documentation; can we use the pathology report to determine the correct size for CPT selection?
Answer:
No; the provider must document the hernia defect size within his/her operative report details to accurately select the correct CPT code. The pathology report would likely represent the tissue size, which would not necessarily correlate to the defect size. Best practice is to send a query to the provider asking him/her to add an addendum to the operative report, adding the defect size and advise that this information is required in the documentation.
*This response is based on the best information available as of 2/27/25.
Reporting An Unlisted CPT Code
What is needed to report an unlisted CPT code?
Question:
What is needed to report an unlisted CPT code?
Answer:
To report an unlisted CPT code, you must first make certain that no code exists that represents the procedure in its entirety or with a modifier that would represent what was performed (e.g., modifier 52 for reduced services). Once it is determined that there is no existing code to represent the work, choose a code from the appropriate anatomical section of CPT, the appropriate approach (i.e. open vs laparoscopic), and compare the unlisted code to another code that most closely resembles the anatomical area, approach (if possible) and work involved to accurately compare RVUs and reimbursement expectations.
*This response is based on the best information available as of 2/13/25.
Global period for hernia repair
Do all hernia repairs have a 90-day global period?
Question:
Do all hernia repairs have a 90-day global period?
Answer:
No; inguinal, femoral and lumbar hernias have a 90-day global period. However, abdominal and parastomal hernia repairs have no global period, so E/M and other procedures may be separately reported with appropriate documentation the day following the procedure.
*This response is based on the best information available as of 1/30/25.
Discrepancy between Procedure Title and Documentation Details
If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?
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.