Epistaxis

Question:

If I perform a nasal endoscopy to localize the site of a nosebleed, then remove the scope and use a nasal speculum to cauterize, can I report both 31231 and 30901?

Answer:

You should not report both CPT code 31231 and 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) for this procedure.  CPT code 30901 would be the most appropriate choice for cauterizing a nosebleed. 31231 is a diagnostic procedure and includes the parenthetical statement “separate procedure.” This code is included in a more definitive therapeutic/treatment procedure at the same operative session. Report either CPT code 31231 or 30901, but not both codes.

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

Modifier 80 vs. 82

Question:

What is the difference between modifier 80 and modifier 82 when a physician is acting as an assistant during surgery?

Answer:

While both modifier 80 and modifier 82 are used when a physician is actively participating as an assistant to a primary surgeon during a surgical procedure, the modifier 82 is used in teaching or university hospitals that have approved Graduate Medical Education (GME) programs for residents. In these teaching hospitals, there must be documentation indicating that no qualified resident was available to assist to allow for another physician to act as the assistant surgeon, and then modifier 82 is appended to that assistant surgeon.

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

EAC Closure Coding

Question:

Is a "blind sac EAC closure" included in codes 69603 and 69530? Or would the closure be billed separately?

Answer:

Thank you for your question.

CPT codes 69603 and 69530 do not include a "blind sac closure" of the external auditory canal (EAC).

• CPT code 69603 is for a tympanoplasty with mastoidectomy, which includes a meatoplasty (widening of the ear canal entrance) but not a blind sac closure

• CPT code 69530 is for a radical mastoidectomy, which also does not include a blind sac closure

A blind sac closure is a separate procedure involving the permanent closure of the external auditory canal, and it would need to be coded separately. This would be reported with the unlisted code 69399 since there is no specific code for this procedure. You can use CPT 69603 or 69530 as the comparison code.

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

Discrepancy between Procedure Title and Documentation Details

Question:

If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?

Answer:

CPT codes are always chosen based on the documentation within the detailed portion of an operative record. If the details within the body of the report do not match the “procedure title” listed in the beginning of the operative report, the provider should be queried for clarification and a possible addendum to the record if necessary.

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

Difference between Preoperative and Postoperative Diagnoses

Question:

Is there a difference between a preoperative diagnosis and a postoperative diagnosis?

Answer:

Preoperative diagnosis is based on the “reason for the surgery” or the condition affecting the patient leading to the necessity of the surgery. Underlying co-morbidities that can affect the surgical outcome or represent a risk to the patient can also be included but the documentation must support their relationship to the patient risk.

Postoperative diagnoses are based on the findings determined during the surgical procedure. Post-op diagnosis may be the same as the pre-op diagnosis or may be more definitive.

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

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. Best practice is to set a fee for the extra physician work involved with robotic assistance, document medical necessity for 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 2/27/25.