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.

Bioinductive Implants

Question:

When providers use bioinductive implants to reinforce rotator cuff repairs or other musculoskeletal procedures, what is the best way to report them?  CPT code 17999 is often suggested, but CPT Assistant references imply that this unlisted code should only be reported with codes in the integumentary system.

Answer:

Thank you for your inquiry. CPT code 17999 is an unlisted code for the integumentary system. It is used for procedures performed on skin, mucous membranes, and subcutaneous tissue and is not appropriate for use with these procedures.

The bioinductive implant or patch is usually secured with small anchors or sutures to position it correctly on the tendon, provide mechanical support, and enhance biological healing after an arthroscopic rotator cuff repair. This is not a normal part of a standard rotator cuff repair, and therefore, with supporting documentation, KZA recommends CPT code 29827 with modifier 22 for increased procedural service. There is no additional reporting for the biologic implant on the surgeon’s professional claim; however, the ASC or hospital could report the implant on the facility claim.

*This response is based on the best information available as of 4/10/25.

Cast Overwrapping

Question:

Can a practice report a CPT code for a cast application code if they only place a fiberglass overwrapping to current cast?

Answer:

The practice will report a supply code only if the old cast was not removed and replaced but only had additional wrapping placed.

An example may be the overwrapping of a previously applied bivalved cast. The practice would not report a new cast application code but may report the supply code.

*This response is based on the best information available as of 3/27/25.

Physician Assistant Billing for New and Established Patients

Question:

Our Physician Assistant saw a new Medicare Patient in the office for evaluation of left knee pain. She evaluated the patient and developed the plan of care. The patient was scheduled for a return visit with the Physician Assistant. During the return visit, the Physician Assistant evaluated the patient and made no changes to the plan of care—she continued the NSAIDs as the patient responded well.

Can she bill this  “Incident to” the physician who was in the office, as there was no change in the plan of care?

Answer:

Thanks for your inquiry. Although the second visit involves an established patient with no changes to the plan of care or new orders, the Physician Assistant must  submit the claim as the service provider. The 'Incident to' requirements have not been met.

To move this to an “Incident to” encounter, there must be an independent encounter with the physician who either agrees with or changes the plan of care. After the physician independently evaluates the patient and either agrees with or modifies the plan of care, subsequent encounters with the Physician Assistant may be reported as 'Incident to' if the requirements are met (e.g., implementation of the plan of care without new orders or changes to the plan of care).

*This response is based on the best information available as of 3/13/25.