Is Documentation of HPI and Exam Necessary in Determining a Level of E/M?

Question:

With the 2021 and 2023 Guideline changes, is it necessary to document an HPI and Exam when neither counts towards the level of service?

Answer:

As described in the most recent AMA E/M guidelines, documentation of a history of present illness (HPI) and an exam are no longer required to contribute to the level of an E/M service. Today, documentation of medical decision making, or time are the sole determinants supporting a level of E/M. E/M documentation should include a medically appropriate history and examination. While the nature and extent of the history and exam is to be determined by the clinician, they add to the medical necessity of the visit and provide a more complete representation of the patient condition for continuity and coordination of care with other clinical providers.

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

Non-Selective vs Selective Catheterization

Question:

What is the difference between non-selective and selective catheterization?

Answer:

Non-selective catheterization is when the catheter remains in the accessed vessel site (puncture site) and is not navigated further into other vessels. Selective catheterization is when the catheter is manipulated out of the access vessel, or out of the aorta, to additional vessels.

*This response is based on the best information available as of 2/27/25.

Stent and Atherectomy in the Femoral and Popliteal Arteries

Question:

If a stent is placed in the common femoral artery and an atherectomy is performed in the popliteal artery, can both codes be billed? 

Answer:

The femoral/popliteal is one territory, so angioplasty, atherectomy and stent are reported with one code regardless of the number of interventions performed.  CPT code 37227 represents stent and atherectomy within the same vessel and also includes angioplasty when performed. 

*This response is based on the best information available as of 2/13/25.

Modifier for Bilateral Catheterization

Question:

Do you code bilateral catheterization codes with modifier 50? 

Answer:

Catheterization codes below the diaphragm can be coded with bilateral modifier 50, however, catheterization codes above the diaphragm should be coded with modifier 59 on the second code. (ex. Lower extremity 36245-50, upper extremity 36215, 36215-59). 

*This response is based on the best information available as of 1/30/25.

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 1/16/25.

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, 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 1/2/25.