Coding for Traumatic Serosal Tear

Question:

How do you recommend coding for a traumatic transverse colon serosal tear? My coder used "repair of transverse colon." I am getting push back because I said it was a clean case (no spillage of GI contents and no contamination." I am told I can't use Clean classification because of how it was coded. Please advise!

Answer:

Serosal tears after trauma are not separately reported. They are included in the primary procedure. The colon was not lacerated/injured and was not repaired so colon repair may not be reported.

*This response is based on the best information available as of 10/23/25.

Pyogenic Granuloma

Question:

Hello! Could KZA clarify if the excision of a pyogenic granuloma (lobular capillary hemangioma) would be assigned to a code from the musculoskeletal or integumentary system? We have seen some conflicting information.  

Answer:

Thank you for reaching out to KZA!

The origin of the lesion will direct you to the appropriate code selection.

According to CPT:

• Lesions of cutaneous origin are appropriately reported with the excision of lesion integumentary codes (114xx & 116xx).

• Lesions of non-cutaneous origin are appropriately reported with the excision of tumor codes from the musculoskeletal section of CPT (2xxxx).

Pyogenic granulomas are benign, generally considered of cutaneous origin, and reported with a 114xx benign lesion code. If the documentation is unclear, it is best practice to query the surgeon for clarification.

*This response is based on the best information available as of 10/09/25.

Reporting Modifiers with Unlisted Codes

Question:

Can modifiers be reported with unlisted CPT codes?

Answer:

Yes, modifiers can be appended to unlisted CPT codes.

In 2024, CPT clarified this by updating the introduction guidelines for unlisted procedures and services. These updates were further explained in the January 2024 issue of CPT Assistant, which addressed the new and revised text and the standardization of reporting unlisted CPT codes across the CPT code set.

Illustration of modifiers that may be appropriately applied includes:

• Laterality modifiers – e.g., RT (right), LT (left)

• Bilateral procedure modifier – 50

• Role-based modifiers – e.g., 62 (two surgeons), 80 (assistant surgeon), 82 (assistant surgeon when qualified resident not available), AS (non-physician surgical assistant)

• Multiple or distinct procedure modifiers – e.g., 51 (multiple procedures), 59 (distinct procedural service)

• Global modifiers – e.g., 58 (staged or related procedure), 78 (return to operating room for related procedure), 79 (unrelated procedure or service)

This is not an all-inclusive list of modifiers that may be appropriately applied to unlisted CPT codes. For complete and up-to-date information, one should refer to current CPT guidelines and payer-specific policies.

Please note: Modifiers that describe an alteration of a service or procedure, such as modifier 52 (reduced services), are not appropriate for use with unlisted codes. The same applied to modifier 22 (increased procedural services).

*This response is based on the best information available as of 9/22/25.

Is CPT 20660 separately reportable with 61313?

Question:

My surgeon wants to bill CPT 20660 and CPT 61313. Is 20660 appropriate to report in addition?

Answer:

Great question! Thank you for asking KZA!

If you review the CPT descriptor for CPT 20660, this is a designated separate procedure.

First, let’s review what a “separate procedure” is:

CPT Says: “Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

However, when a procedure or service that is designated as a “separate procedure” is carried out independently or considered to be unrelated or distinct from other procedures, report the code in addition to other procedures/services by appending modifier 59 to the specific “separate procedure” code. This indicates that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).”

That said, this means in practice that if a code description includes the term “separate procedure,” if that procedure is in the same anatomic area as a more comprehensive procedure (for example, application of a headframe followed by a craniectomy), only the more comprehensive procedure, the craniectomy (61313), is reported.

*This response is based on the best information available as of 9/25/25.

Two Procedures on the Same Day

Question:

If a patient develops a complication from a surgical procedure during the global period and needs to return to the OR for treatment, will the second procedure require a modifier and if so, which modifier? We are debating whether it would be a modifier 58 for staged procedure, or 78 for an unplanned return to the OR.

Answer:

Modifiers 58 is appended to a subsequent procedure if it is staged or more extensive than the original procedure. Modifier 78 is for an unplanned return to the OR, typically a complication. Therefore, in the scenario you describe, a modifier 78 for an unplanned return for a complication would be the appropriate modifier.

*This response is based on the best information available as of 8/28/25.

How Do You Bill for H&P?

Question:

The hospital requires our surgeons to perform and document an H & P prior to the patient having an elective gall bladder surgery. Sometimes it’s done in the office before the surgery and sometimes it’s done on the same day as the procedure. If this H & P is documented, can the E/M be billed? And does it make a difference if it’s done a week before the surgery?

Answer:

A pre-operative H & P, regardless of when it occurs, is included in the global surgical package and is not separately billable. CPT clarified this in 2009 in a CPT Assistant comment, see below:

“If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.” (Source CPT May 2009)

*This response is based on the best information available as of 8/14/25.