I&D in the Office during the Global Period

Question:

Our surgeon saw a patient in the office for a routine post-op check during the global period of an excision of a soft tissue tumor. During the visit the surgeon notes that the patient has some fullness and performs a superficial incision and drainage in the office. I have the correct CPT code, but I am wondering if I should use Modifier 58 or 79. I think the correct modifier is modifier 79 because he documents a new diagnosis “seroma”. Do you recommend modifier 58 or 79?

Answer:

The reporting (or not) of this service performed in the office during the global period will be payor dependent. If the payor is Medicare, or follows Medicare rules, the visit is not reportable as this a complication of the original surgery.

If the payor follows CPT rules, and the surgeon determines this is not “typical postoperative care” then traditionally no modifiers are appended. Modifier 79 is typically reserved for an ‘unrelated’ procedure/ service at a different location. The seroma is secondary to the surgical intervention—thus if there had not been surgery, there would not be a seroma.  Modifier 58 is incorrect as this is not a planned procedure, is not more extensive, and is not part of the treatment plan.  Survey your private payors to determine which modifier, if any, is required.

*This response is based on the best information available as of 12/13/18.

CPT Code 20610 or 20611?

Question:

Our physician performed a shoulder joint injection with ultrasound guidance.  The physician’s procedure note does not fully detail the ultrasound guidance, other than the ultrasound was used to do the injection. The physician does not document that images were saved (and we can’t find images).  The physician also does not have a separate report for the interpretation.  I am thinking we should report 20610 (large joint injection without ultrasound guidance) versus 20611 (large joint injection with ultrasound guidance).   Do you agree with my choice?

Answer:

Yes, the AMA published specific documentation requirements for the ultrasound-guided joint injections (20604, 20605 and 20611) when the codes were introduced in 2015.   In the absence of such documentation, the correct code is 20610.

CPT code 20611 requires the following:

• Documentation of a focused ultrasound evaluation.
• Obtain, label, and interpret images in multiple planes through the specific area of concern.
• Documentation of the normal anatomic structure and any pathologic findings.
• Documentation of separate stand-alone report for the patient’s chart (CPT code and radiology requirement).
• Documentation the procedure itself, including prep, intraservice work, and patient tolerance.
• Documentation of the specific medication and dosage if a therapeutic injection was performed.

*This response is based on the best information available as of 11/01/18.

Bone Marrow Aspirate

Question:

Our surgeon aspirated bone marrow for a subtalar fusion. We are unsure how to report this. Are you able to help?

Answer:

Yes, with the guideline changes surrounding CPT code 38220 and the new code 20939, CPT instructs to report 20999 for bone marrow aspirate for other musculoskeletal fusions (non-spine).

(For aspiration of bone marrow for the purpose of bone grafting, other than spine surgery and other therapeutic musculoskeletal applications, use 20999)

*This response is based on the best information available as of 08/09/18.

Multiple Fasciotomies Same Hand for Dupuytren’s

Question:

Our hand surgeon, not infrequently, will perform multiple fasciotomies in the hand for the treatment of Dupuytren’s.  We are reporting CPT code 26045 for each fasciotomy but now we are Question:ing if this is correct or not.  Before we refund claims paid, will you tell us if this code is reportable multiple times in the same hand?

Answer:

CPT code 26045 (Fasciotomy, palmar (eg, Dupuytren’s contracture); open, partial) is reportable one time regardless of how many “fasciotomies” were performed.   The only time this code is reportable twice on the same day is if both hands were treated. The code is a “palmar” code, thus includes all work on the same palm.

*This response is based on the best information available as of 07/26/18.

Total Hip Arthroplasty Question

Question:

We have a patient who underwent an open fixation of a femoral neck fracture five years ago and now presents for a total hip arthroplasty.   Someone mentioned that we should report a conversion to hip arthroplasty but we are not sure if this is a revision of one component plus a hemiarthroplasty?

Answer:

The advice you received related to reporting this as a conversion to total hip arthroplasty is correct.  The patient is not in a global period, so you will report 27132 (Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft).  The concept of reporting the conversion code versus a primary hip arthroplasty is that the patient has had prior open hip surgery, and the value of the conversion code reflects that the procedure is typically more difficult than a primary arthroplasty procedure.

Do not unbundle and report the removal of one component and a hemi-arthroplasty or other revision codes for the described circumstance.

*This response is based on the best information available as of 06/14/18.

Confused about CPT Code 26600

Question:

I am confused on how to report the closed treatment of multiple metacarpal fractures (26600) that are not displaced and treated with the application of a fiberglass short arm cast.    We are receiving denials when reporting the code for each fracture.

Answer:

The official definition of CPT code 26600 (Closed treatment of metacarpal fracture, single; without manipulation, each bone) instructs the physician to report CPT code 26600 for each bone that is fracture and treated without manipulation.

Several years ago, CMS implemented NCCI guidelines instructing that non-manipulative fractures that are treated with a single form of stabilization (e.g. cast) may only be reported as a single fracture.  This NCCI guideline also applies to situations where a patient may have both a displaced and non-displaced fracture treated with the same cast or splint.

The denials are correct if the payor is Medicare based on NCCI edits.  If the denials are coming from private payors, review the contracts to determine if the claim processing rule is agreed to in the contracts.  Appeal all denials to private payors citing CPT rules and hopefully contract agreement language.

*This response is based on the best information available as of 05/31/18.