Coding Breast Biopsies 19120 vs 19125 and 19126

Question:

I’m confused as to why 19120, excision of breast mass requires different incisions to bill two excisions, when 19125 and +19126 removing two breast masa with a wire or marker does not require separate incisions.

Answer:

Code 19120 is a primary case and as such includes the exposure ( opening), the excision of the mass and the closure. So, to bill a second 19120, a second exposure and closure must be performed to support a second primary code. With codes 19125 and +19126, the code for the second excision and removal is an add on code. As an add on code, the value is reduced, does not include an exposure and closure, and is only valued for the intraoperative work. Therefore, a separate incision is not required for removal of a second mass via the same incision.

*This response is based on the best information available as of 06/022/23.

E&M Coding Based on Time

Question:

When choosing the level of E&M we are confused about the History and Exam. If we choose a level of E&M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E&M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (eg, review of tests);

• obtaining and/or reviewing separately obtained history;

• performing a medically appropriate examination and/or evaluation;

• counseling and educating the patient/family/ caregiver;

• ordering medications, tests, or procedures;

• referring and communicating with other health care professionals (when not separately reported);

• documenting clinical information in the electronic or other health record;

• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and

• care coordination (when not separately reported).

source: CPT Assistant April 2022

*This response is based on the best information available as of 06/08/23.

Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

*This response is based on the best information available as of 05/25/23.

Code +15777 for Placement of a Non-biologic Implant. Is this the Correct Code?

Question:

I placed a non-biological implant for abdominal soft tissue reinforcement. Can this be coded as +15777?

Answer:

No. Code +15777 is reported specifically for abiological implantfor soft tissue reinforcement implant in breast or trunk only. Code +0437T, a Category III code, is reported for implantation of anonbiologic or synthetic implant(eg, polypropylene) for fascial reinforcement of the abdominal wall. A Category III code is intended as a temporary or tracking code, and payment is carrier determined. Payors may consider Category III codes to be investigational and therefore not covered. To increase chance of payment, have always have the procedure pre-authorized.

*This response is based on the best information available as of 05/11/23.

Reporting a Cholecystectomy and an Umbilical Hernia at the Same Operative Session

Question:

If a patient undergoes an open cholecystectomy and has a reducible umbilical hernia repaired during the same operative session, through separate incisions, can both be reported?

Answer:

Yes, if both procedures were performed through separate incisions both may be reported. Conversely, if both were repaired through the same incision, only the cholecystectomy would be reported.

*This response is based on the best information available as of 04/27/23.

Reporting a Cholecystectomy with a Cholangiogram

Question:

If a cholangiogram was performed by the surgeon during a cholecystectomy, but the radiologist interprets it, is 47563,Laparoscopy, surgical; cholecystectomy with cholangiographystill appropriate?

Answer:

Yes, the codes “with cholangiogram” are valued for intraoperative physician work, not the interpretation.

*This response is based on the best information available as of 04/13/23.