Decision for Surgery: Always a Level Five?

Question:

If the surgeon documents the decision for surgery and places the standard risk paragraph for that surgery, is this automatically a high level of risk?

Answer:

Thank you for your inquiry as this is not an uncommon question; we discuss this at length in the KZA coding courses.

There are two risk levels associated with the decision for surgery:

• Moderate: Decision for Surgery without documentation of procedure risks and patient specific risks for that surgery.

• High Risk: Decision for Surgery with documentation of procedure risks and patient specific risks for that surgery.

Remember, this Risk Element is only of the three Medical Decision Making (MDM) Elements. To meet a level four or level five encounter, two of the three MDM Elements either need to be at or meet the associated E&M level.

1. The number and complexity of problems addressed.

2. The amount and/or complexity of data to be reviewed and analyzed.

3. The risk of complications and/or morbidity or mortality of patient management.

*This response is based on the best information available as of 7/03/25.

Erector Spinal Block with Discectomy

Question:

Our surgeon states in the procedure title “Fluoroscopic Erector Spinae Block (ESP) L5”. The documentation supports this as performed bilaterally at L5 prior to the surgical incision. Is this separately reportable?

Answer:

Thank you for your inquiry. It appears you have good documentation; however, this block is inclusive of the surgical procedure when performed by the operating surgeon. The timing of this (pre-incision) and fluoroscopically vs post discectomy, does not change the injection as being inclusive.  

*This response is based on the best information available as of 6/19/25.

Postoperative Pain Block by Surgeon

Question:

This question may fall outside the interventional pain questions typically submitted to KZA.

Our surgeon is performing a total knee replacement and a postoperative pain block on a Medicare patient. Can we report the block in addition to the total knee arthroplasty procedure?

Answer:

Thank you for your submitted question!

Both CPT and CMS consider postoperative pain management by the physician performing the surgical procedure to be included in the global surgical package and not separately reportable.

Based on the submitted scenario, the surgeon's appropriate coding is 27447 for the total knee arthroplasty.

*This response is based on the best information available as of 5/22/25.

Risk of Patient Management

Question:

Our new surgeon wants to code a level five encounter for all patients where the patient is scheduled for inpatient surgery. He states he was educated that all outpatient surgeries are automatically a level four encounter, and all inpatient surgeries are automatically level five encounters. Have we been assigning the level of risk incorrectly?

Answer:

Unfortunately, it sounds as though the surgeon received incorrect information.

The risk of patient management (one of three MDM Elements) is based on the procedure risks and patient specific risks for the surgical procedure. Whether the surgery is inpatient or outpatient is not a factor in determining the risk level for the encounter.

Let’s look at CPT’s MDM table under “Risk of complications and/or morbidity or mortality of patient management as a possible source of confusion.

CPT provides several examples for high risk:

· “Decision regarding hospitalization or escalation of hospital level care.”

· “Decision regarding elective major surgery with identified patient or procedure risk factors”

· “Decision regarding emergency major surgery”

If one of these criteria is met, then the provider reaches high risk as one of the elements of MDM. To bill the service as high risk, one of the two other elements (number and Complexity of problems addressed at the encounter or amount and/or complexity of data to be reviewed and analyzed) must also be at high.

This level of E/M service is associated with a presenting problem where the patient requires hospitalization for management of the presenting problem/condition and meets the MDM elements criteria not for surgery itself.

Trigger Finger Release with Tenosynovectomy

Question:

In our practice, we often receive cases where the patient comes in for trigger finger release. Tenosynovitis is also identified after the procedure starts. In addition to performing the trigger finger release, a tenosynovectomy is performed on the involved tendon. Can we report both?

Answer:

Thank you for your inquiry.

According to AAOS Global Service Data, tenolysis or tenosynovectomy is included in procedure code 26055, and any tenolysis or tenosynovectomy would not be separately reported. Additionally, there are NCCI edits between 26055 and 26440 /26442, respectively. The edit may not be bypassed with a modifier.

The intent of the surgery is to release the trigger finger, which would be appropriately reported with CPT 26055.

*This response is based on the best information available as of 5/8/25.

Arthrodesis With Local Graft

Question:

What is the appropriate CPT code to report when local autograft is used and taken from the reamings and allograft is used for arthrodesis of the IP joint? Which CPT code is correct, 26862 or 26860?

Answer:

Thank you for your question.

CPT 26860 includes using locally obtained autograft bone in addition to the allograft. In contrast, CPT code 26862 is reported when an autograft is obtained from a separate site and is valued for the additional work involved in obtaining that graft from a separate anatomical location.

Based on the question and presented scenario, the correct CPT code is 26860.

*This response is based on the best information available as of 4/24/25.