2021 EM Guidelines: Only for Medicare?

Question:

I work with a surgeon and we see just a few Medicare patients. The surgeon believes the revised 2021 E/M guidelines will not impact our office practice because of our low Medicare volume.

Is this correct?

Answer:

This is not correct and is a common misconception. The revised documentation requirements come from the American Medical Association (AMA) for CPT™. These are the folks that write the codes, not a specific payor.

The changes were essentially agreed to by the Center for Medicare and Medicaid Services (CMS), but they are changes to the code descriptors and guidelines in CPT. One of the primary goals of the change, other than simplification, is standardization. We know that commercial payors and CMS have a variety of documentation standards to support a level of E/M service. Beginning in January 1, 2021, CPT™ has standardized the documentation of the specific level of new and established outpatient visit, which should be applicable to all commercial and government payors.

*This response is based on the best information available as of 04/7/22.

Hartmann or Partial Colectomy

Question:

My surgeon performed all the components of a Hartmann procedure 44143 but did not create a colostomy. Can we use 44143 with a -52 modifier?

Answer:

The correct code for this procedure would be 44140.  Code 44140 is the base code for 44143 with the only difference being a skin level colostomy, so it would be inappropriate to code 44143-52 as there is an established code already in place.

*This response is based on the best information available as of 03/24/22.

Billing for a Wound Vac

Question:

Can you bill for a wound vac on a surgical incision if the patient has a history of incision infections to help prevent this?

Answer:

The AMA published clarification on wound vac billing in the October 2021 CPT Assistant. Negative pressure wound therapy (97605-97606) is considered billable for both open and closed wounds. However, that does not mean that payors will reimburse separately for the service, so use caution and track results.

*This response is based on the best information available as of 03/10/22.

Using Modifier -22 for Adhesiolysis

Question:

My provider indicated that it took her an additional 80 minutes during a surgery to perform adhesiolysis. Is documentation of the time sufficient?

Answer:

Although time (specific minutes) should always be indicated in the operative note, the provider must also give the reasonwhythe lysis took longer (what complicated this part of the surgery). For example, the patient’s BMI was 42 or history of 10 previous abdominal surgeries. This is true any time modifier -22 is used for any procedure, not just for lysing adhesions.

*This response is based on the best information available as of 02/24/22.

Billing E/M Visits During the Global Period

Question:

Can I bill different diagnosis codes for conditions/problems when seeing a patient in the hospital after surgery, but during the stay of a major surgery?

Answer:

It depends. You cannot bill for related issues or known complications that arise from the surgery, but you can bill for unrelated conditions/problems with proper documentation that supports billing. It must be clear in the documentation that the condition is unrelated with a clear plan of treatment for the new/unrelated issue. You would need to add a modifier -24 to any unrelated E/M service performed.

*This response is based on the best information available as of 02/10/22.

Coding a Diverting Ileostomy with a Low Anterior Resection/Low Pelvic Anastomosis Partial Colectomy

Question:

Instead of a colostomy as described in the laparoscopic CPT codes 44208 or the open code, 44146, my doctor does a diverting ileostomy.  We have been billing the primary codes 44145 or 44207 and adding the ileostomy code, 44187 if laparoscopic or 44310 if open.  Is that correct?

Answer:

Partial colectomy with anastomosis and colostomy (codes 44146, open or 44208, laparoscopic) includes creation of a colostomy (stoma of the large intestine) or ileostomy (stoma of the small intestine). The clinical description of this code, written when the code was developed, describes either external opening, so the codes are valued to include either an ileostomy or colostomy. So the correct coding is 44146 or 44208 when a low anterior resection/low pelvic anastomosis partial colectomy and a diverting ileostomy is performed instead of a colostomy.

For more information on colorectal coding, take a look at the KZA webinarColorectal Surgery Coding and Reimbursement, orcontact usfor more information.

*This response is based on the best information available as of 01/27/22.