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 09/8/22.

Billing for Costotransversectomy

Question:

If the exposure is thoracic, for example in a thoracic corpectomy, and the documentation states a costotransversectomy was performed, can that be billed separately?

Answer:

Costotransversectomy (e.g., 21610) is included in a thoracic corpectomy and not separately billed. Note also that 21610 states “separate procedure” so it is never billed with a more inclusive code.

*This response is based on the best information available as of 08/25/22.

Coding for Spine Procedures that Cross Spinal Junctions

Question:

How do you report a spinal procedure for example, arthrodesis or laminectomies when two spinal are involved. For example., both thoracic and lumbar spine?

Answer:

Report one stand-alone/primary code even when the procedure crosses spine junctional levels. Use the stand-alone code for the spine region where the majority of the procedure/levels is performed.

• Example:T11-S1 posterolateral arthrodesis (T11-T12, T12-L1, L1-L2, L2-L3, L3-L4, L4-L5, L5-S1)
  Use 22612 (the lumbar stand-alone code, since more level were lumbar) and +22614 x 6

*This response is based on the best information available as of 08/11/22.

Removal of Interbody Device

Question:

Can code 20680, removal of implant, be used for removal of a previously placed intervertebral device, such as a PEEK cage?

Answer:

No. There is no code for removal of an intervertebral device – this would be part of an exploration of arthrodesis or new arthrodesis, if performed. Do not use 20680 (removal of implant) for removing spine instrumentation.

*This response is based on the best information available as of 07/28/22.

Coding for Percutaneous Screws and Rod Placement

Question:

I placed posterior percutaneous screws and rods without an arthrodesis. I know I have to use an unlisted code, 22899. How should I price it?

Answer:

Good question. Let’s assume you’re doing +22842 (posterior instrumentation, 3-6 segments) which is an add-on code. Add-on codes are valued for only the intra-operative portion of the service and do not include any value for pre-op (e.g., H&P, discussion with patient), certain intra-operative work (e.g., incision, closure) or post-op work.

Recall that Medicare reduces the payment for secondary stand-alone procedure codes by 50% to account for overlapping pre- and post-op work.

Therefore, we recommend you double your fee for +22842 to achieve your fee for the unlisted code. For example, if your fee for +22842 is $100 then your fee for the unlisted code would be $200.

*This response is based on the best information available as of 07/14/22.

Modifiers on Unlisted Codes. Yes or no?

Question:

Can I use modifiers on an unlisted code?

Answer:

There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers are not appended to an unlisted code.

Payors have their own rules. For example, some payors will accept modifier 62 (two surgeons/co-surgery) on an unlisted code such as 64999 while other payors do not.

We would not append modifier 50 (bilateral procedure) to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22.

We also would not append modifier 51 (multiple procedures) to an unlisted code. Let the payor take the discount.

What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code.

*This response is based on the best information available as of 06/30/22.