E/M for an Acute Problem

Question:

How do we code for a new patient seen in the office with RUQ upper quadrant discomfort with suspected cholecystitis and an order for ultrasound?

Answer:

A new patient with an acute problem (or “suspected” may be viewed as undiagnosed), with minimal data (order) and minimal/low risk for the ultrasound, would be 99203.

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

Laparoscopic Mobilization of Splenic Flexure With Open Colectomy

Question:

Our provider began a laparoscopic procedure for colectomy and completed the mobilization of the splenic flexure laparoscopically, but then needed to convert to an open procedure to perform the colectomy. What is the correct coding for laparoscopic mobilization of the splenic flexure with open colectomy?

Answer:

When a laparoscopic procedure is converted to an open procedure, you can only code for the open procedure, so in this case, only code for the appropriate open colectomy code; the laparoscopic mobilization of the splenic flexure is not separately billable.

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

Inpatient Consultation Coding for Medicare

Question:

If you see a Medicare patient for the first time in the hospital as an inpatient consultation, what code would you bill for the EM?

Answer:

The EM would be reported as an Initial hospital or observational care codes (99221-99223) with the appropriate level based on MDM or Time. Medicare does not allow payment for inpatient consultation codes 99252-99255.

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

Esophageal Sphincter Augmentation for GERD

Question:

How is esophageal sphincter augmentation for GERD reported?

Answer:

Report CPT code 43284 for laparoscopic placement of the augmentation device (i.e. magnetic band). CPT code 43285 is reported for subsequent removal of the device.

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

Abdominal Hernia Defect Size

Question:

Our general surgeon often does not include the size of the abdominal repair in his documentation; can we use the pathology report to determine the correct size for CPT selection?

Answer:

No; the provider must document the hernia defect size within his/her operative report details to accurately select the correct CPT code. The pathology report would likely represent the tissue size, which would not necessarily correlate to the defect size. Best practice is to send a query to the provider asking him/her to add an addendum to the operative report, adding the defect size and advise that this information is required in the documentation.

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

Reporting An Unlisted CPT Code

Question:

What is needed to report an unlisted CPT code?

Answer:

To report an unlisted CPT code, you must first make certain that no code exists that represents the procedure in its entirety or with a modifier that would represent what was performed (e.g., modifier 52 for reduced services). Once it is determined that there is no existing code to represent the work, choose a code from the appropriate anatomical section of CPT, the appropriate approach (i.e. open vs laparoscopic), and compare the unlisted code to another code that most closely resembles the anatomical area, approach (if possible) and work involved to accurately compare RVUs and reimbursement expectations.

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