Multiple Femoral Fractures

Question:

I am wondering about charging both CPT codes 27506 (femur shaft) and 27245 (femur intertrochanteric). There is an NCCI edit indicating that 27245 is included with 27506 per mutually exclusive procedures. The provider is saying these are two separate injuries/entities and we should use a modifier. However, I am not sure if that would be correct since they are both on the same bone, just different locations of it. Can you please explain if it would be appropriate to code both codes for the same femur? It seems they are using one nail to fix both fractures. What if they are two separate fractures, does that make a difference? I am having trouble locating any guidance for this scenario. Thank you for your insight.

Answer:

If one intramedullary implant is being placed to treat an intertrochanteric, peritrochanteric, or subtrochanteric fracture in addition to a femoral shaft fracture, only one code would be used. There is an NCCI edit stating that they are mutually exclusive procedures, and a modifier would not be appropriate to override the edit. 

Modifier 22 Increased Procedural Services may be appended if the documentation supports that the work required to treat the fractures was substantially greater than typically required. 

Code selection of either 27506 or 27245 should be determined by the provider based on which treatment was more extensive. 

*This response is based on the best information available as of 05/07/26.

Tibial Plateau Fractures

Question:

Can you please clarify if CPT 27536 requires two incisions, one for the medial and one for the lateral to be able to use this code?

Answer:

While the common approach to a bicondylar tibial plateau fracture is by two incisions, one medial and one lateral, it is not required. The bicondylar fracture can be treated by a single midline approach for dual plating. 

What is important is that a bicondylar tibial fracture is being treated.  

CPT description reads: CPT 27536 Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation.

*This response is based on the best information available as of 04/02/26.

Two Stage ACL Treatment

Question:

Our docs have been seeing more patients that have had a re-tear of ACL and are wanting to do bone grafting of tunnels in addition to medial and lateral meniscectomies and removal of hardware and evaluate the ACL to see if it repairable. We are wondering if the bone grafting is separately billable and what code we should use for this?

Answer:

Thank you for your inquiry and recognizing we are not able to provide definitive coding advice without an operative note. This is a good question.

There is no specific CPT code for the first of two stage revision of an ACL. Current guidance for the removal of plugs, debridement of tunnels and filling the tunnels with a bone substitute is coded to 29999. 

*This response is based on the best information available as of 03/05/26.

Biceps Tenodesis or Tendon Transfer

Question:

The provider performs shoulder arthroplasties and also does a bicep muscle transfer to the pectoralis muscle. He bills 23472 for the arthroplasty and then wants to bill 23395 for the muscle transfer. The portion of his note for this procedure is: "I then traced the long head of the biceps brachii from the pectoralis major through the rotator interval and released the biceps from its origin. The biceps tendon was diseased from the groove to its insertion on the supraglenoid tubercle. I then sutured the tendon into the pectoralis major tendon as a muscle transfer." I am not in agreement that this procedure is representative of 23395 and think it should be 23430, which would bundle with the shoulder arthroplasty. Do you have any guidance on the correct use of 23395 and if it is the correct code in this situation? Thank you.

Answer:

Thank you for your question. We have noticed providers trying to bill for 23472 and 23395 vs. 23472 and 23430.  Attaching the biceps tendon to the pectoralis major in the scenario you provided above should be coded to 23430. Reattaching the biceps, regardless of the location it is reattached, is considered a biceps tenodesis and should not be confused with a tendon transfer. 

There is an NCCI edit between 23472 and 23430 which needs to be followed for government payors. CPT Assistant July 2024 as well as the American Academy of Orthopaedic Surgeons' Global Service Data (GSD) both state the biceps tenodesis is not part of the shoulder arthroplasty. A separate diagnosis for the biceps pathology should be added and linked to CPT 23430.

*This response is based on the best information available as of 02/05/26.

X-Ray Coding: Is it the Hip or the Pelvis?

Question:

Can someone please answer the question of if the AP pelvis view is counted as a few when coding hip codes? For example, AP pelvis then 2 individual pictures of each hip AP & Lat; would this be coded as a 73523 (1V pelvis + 2V LT + 2V RT) or would this be coded as 73521 (AP and Lateral Views)? How would you code AP pelvis and 1V of LT Hip? 73501 since it is 1V Hip including AP Pelvis or 73502? There is conflicting information about whether you count the Pelvis as a view and whether you count the individual views done for each side.

Answer:

Thank you for reaching out. If you are performing AP pelvis then 2 individual pictures of each hip AP & Lat; you would code 73523 Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views.  This is consistent with the AMA's Clinical Examples in Radiology guidelines from fall of 2015.

*This response is based on the best information available as of 01/22/26.

Help! Can You Clarify Radiology Documentation Requirements?

Question:

We are just looking for clarification of the Interpretation for Radiology services. We have been including them in our E/M notes for years. Can you please explain exactly what it is payors like UHC are requesting/requiring? Are they wanting a report of that Radiology exam on a separate form altogether?

Answer:

You're not the only one who has been including the interpretation in the E/M.

CPT guidelines in the introductory section of the radiology chapter 70000-79999 states a written report signed by the interpreting individual is considered "an integral part of a radiologic procedure or interpretation." This means radiology interpretation requires formal, separate documentation—not just findings mentioned within an E/M note. The written report must contain interpretive findings and documentation of the imaging performed.

The CPT exception is if the CPT code includes imaging. For example, CPT 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting includes image guidance. Since the imaging is part of the procedure, you document the imaging guidance within your procedure note rather than as a separate radiology report.

This is also consistent with CMS where the payment conditions for radiology services where Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures states: "The interpretation of a diagnostic procedure includes a written report.”

*This response is based on the best information available as of 01/22/26.