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.

Collagen Dressings

Question:

Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?

Answer:

Thank you for your inquiry.  Several factors have to be considered.

First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.

Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.

Per Medicare Claims Processing Manual, Chapter 12, Section 40.1

o   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket.  Depending on medical necessity, the dressings may or may not be covered under a home health benefit.

Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.

Per Medicare LCD L33831:

Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)

A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal.  They can stay in place for up to 7 days.  Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

To justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order Criteria (SWO)

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.

Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.

LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings. 

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831

As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).

*This response is based on the best information available as of 10/17/24.

Component Seperation

Question:

Our provider has documented abdominal closure by component separation, is there a separate CPT code for this closure or is it included in the main procedure?

Answer:

Component separation, sometimes referred to as a rectus advancement flap, refers to a myocutaneous flap of the trunk (a flap of subcutaneous tissue, fascia and muscle with an intact vascular supply) represented by CPT code 15734. To report this code the providers documentation must demonstrate that the oblique, transversalis or transverse abdominus and rectus abdominus muscles have been incised and mobilized toward the midline with an intact vascular supply. This code can be reported only once for each side and bilateral modifier does not apply, so when performed bilaterally report as 15734, 15734-59.​

*This response is based on the best information available as of 10/3/24.

Documentation for Modifier 22

Question:

What documentation is needed to report modifier 22?

Answer:

To be able to append modifier 22 which represents an increased procedural service, the provider needs to demonstrate that the work required was substantially greater than normally expected. To support this, the documentation must provide more than a blanket statement and include details as to why the work was greater. For example: “extensive lysis of adhesions took greater than 90 mins prior to reaching (the intended site)”.  The “what made it more work” is less crucial than the “details that explain why” it was more difficult so that payors will allow increased reimbursement. 

*This response is based on the best information available as of 7/11/24.