Lysing Adhesions

Question:

The patient had extensive adhesions that had to be lysed. Is it appropriate to report 44005, enterolysis (freeing of adhesion), along with the code for the primary surgery?

Answer:

No, 44005 enterolysis (freeing of adhesions) for an open procedure and 44180, Laparoscopic enterolysis, are both designated as “separate procedures.” They are considered integral to the primary procedure at the same anatomic site. Appending a modifier 22 would be appropriate to reflect the additional work performed.

Source: ACS Bulletin November 2019

*This response is based on the best information available as of 08/03/23.

Billing a Right Colectomy with a Diverting Loop Ileostomy

Question:

How is a right colectomy with a loop ileostomy reported?

Answer:

A loop ileostomy with a right colectomy is reported with 44160 (open) or 44205 (laparoscopic) and creation of an ileostomy; code 44130 (open) or code 44187 laparoscopic. This reflects the additional work of creating the external opening; the ileostomy.

Source: ACS Bulletin November 2019

*This response is based on the best information available as of 07/20/23.

Billing Two Hernias

Question:

The surgeon performed a laparoscopic repair of an initial strangulated ventral hernia and a laparoscopic repair of an inguinal hernia on the same day. Can the surgeon bill for both procedures?

Answer:

Yes, both procedures can be reported with codes 49592, 49594, or 49596, depending on size, and 49650,Laparoscopy, surgical; repair initial inguinal hernia.Because this code pair does not have a National Correct Coding Initiative edit, modifier 51,Multiple procedures, would be appended to the lower-valued code.

*This response is based on the best information available as of 07/06/23.

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.