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.

Pre-op vs Post-op Diagnosis

Question:

Is there a difference between a pre-operative diagnosis and a post-operative diagnosis?

Answer:

Pre-operative 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.

Post-operative 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 12/19/24.

Intravascular Ultrasound (IVUS)

Question:

How do we code for intravascular ultrasound of lower extremity vessels?  Can it be billed along with the placement of a lower extremity stent?

Answer:

Intravascular Ultrasound (IVUS), CPT code +37252 (noncoronary) and +37253 (noncoronary) for each additional vessel, can be coded when vessels are examined during a diagnostic procedure or before, during, or after a therapeutic intervention (e.g., stent or stent graft, angioplasty, atherectomy, embolization, thrombolysis, transcatheter biopsy).  However, if a lesion extends across the margins of one vessel into another, only one code should be reported.  These add-on codes must be reported with the appropriate base code. IVUS is included in the work of CPT codes 37191, 37192, 37193, and 37197 for intravascular vena cava filter (IVC) and should not be reported separately with those procedures. 

*This response is based on the best information available as of 12/5/24.

Documentation for Endovascular Procedures

Question:

What information needs to be documented in the body of the operative report for endovascular procedures?

Answer:

Documentation must include a thorough description of the procedure detailing vascular access points, catheterizations including the end point of all catheterizations, description of all interventions performed including placement of any prosthesis, results of the intervention, percentage of residual stenosis for all vessels treated, and any attempted procedures that were not successful or not able to be completed. Radiological supervision for diagnostic angiograms with rationale, vessels visualized, and findings should also be detailed in a separate paragraph.

*This response is based on the best information available as of 11/14/24.

Lower Extremity Intravascular Lithotripsy

Question:

How do we code for lower extremity Intravascular Lithotripsy (IVL)? Can physicians use HCPCS codes C9764-C9767?

Answer:

There is currently no CPT code to represent physician coding for Intravascular Lithotripsy of the lower extremities. Physicians should not report the facility codes C9764-C9767, instead report these procedures with unlisted vascular CPT code 37799 and compare to an angioplasty code for the same vessel.

*This response is based on the best information available as of 10/31/24.