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Discrepancy between Procedure Title and Documentation Details
If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?
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
Is there a difference between a pre-operative diagnosis and a post-operative diagnosis?
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
What is the code for a robotic procedure?
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.
Tongue Lesion
My physician coded a glossectomy but the documentation in the operative report indicated that a tongue lesion was removed. He wants to code 41120 for the glossectomy. I don’t think this meets the definition of a Glossectomy since there was no mention in the operative report that a portion of the tongue was removed.
Question:
My physician coded a glossectomy but the documentation in the operative report indicated that a tongue lesion was removed. He wants to code 41120 for the glossectomy. I don’t think this meets the definition of a Glossectomy since there was no mention in the operative report that a portion of the tongue was removed.
Answer:
Glossectomy codes require removal of a portion of the tongue, not just the lesion. If your physician is removing a lesion on the tongue, you should report CPT code(s) 41110-41114. When reporting a glossectomy, documentation must include what portion and how much of the tongue was removed. Also be sure to document tongue tissue removal and not just the lesion removal.
*This response is based on the best information available as of 2/13/25.
Extruded Tympanostomy Tube
My surgeon removed an extruded tympanostomy tube from a patient’s left ear under general anesthesia. She wants to code this as 69424-LT for removing the tube. Can you clarify if this is the correct code?
Question:
My surgeon removed an extruded tympanostomy tube from a patient’s left ear under general anesthesia. She wants to code this as 69424-LT for removing the tube. Can you clarify if this is the correct code?
Answer:
Since the tube has moved from its original intended position and no longer serves the intended purpose, it is considered a foreign body. The correct code to report is 69205 (Removal foreign body from external auditory canal; with general anesthesia).
Please review the CPT definition of a Foreign Body versus Implant
CPT Surgery Guidelines for “Foreign Body/Implant Definition.”
“An object intentionally placed by a physician or other qualified heal care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant. An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”
*This response is based on the best information available as of 1/30/25.
Swimmer’s Ear
I am new to ENT coding and am not certain what code I would use. The physician placed an oto-wick in the left ear using the microscope on a patient with swimmer’s ear. Do I just report the microscope code 69990 or do I use a different CPT code?
Question:
I am new to ENT coding and am not certain what code I should use. The physician placed an oto-wick in the left ear using the microscope on a patient with swimmer’s ear. Do I just report the microscope code 69990 or do I use a different CPT code?
Answer:
There is no specific CPT code for ear wick insertion. Ear wick insertion is considered a component of the evaluation and management (E/M) service. If the physician uses the microscope you may report CPT 92504 (Binocular microscopy) in addition to the E/M service.
*This response is based on the best information available as of 1/16/25.