Radiology Reports

Question:

Earlier this year, I attended an education session (not provided by KZA) where radiology reports were discussed. We have been going to KZA courses for many years and have the workbook pages with the history of the requirement and definition change for reports. We were confident we knew the documentation requirements but thought maybe something has changed; we are coming back to KZA for clarification.

In the session, the presenter addressed the need for separate reports; but then said it would be okay if the interpretation was within the office note and not a separate report.

Is a separate report required or not when we report the global radiology codes or the radiology codes with a modifier 26? I just want to make sure nothing has changed.

Answer:

Thank you for your continued support of KZA. Yes, a separate stand-alone report with the professional interpretation (not just review of the X-Rays) is still required. Perhaps the presenter was talking about the documentation requirements when the professional interpretation of external diagnostic studies is documented as part of the E&M note; this interpretation is not separately reportable with a modifier 26; as such a separate stand-alone report is not required. All other interpretation requirements must still be met.

A separate stand-alone report is required if you are billing the global radiology codes or the radiology codes with a modifier 26.

Syndesmosis Repair

Question:

I coded a case for one of our surgeons where he did an ORIF of a distal tibia/fibula fracture (Pilon) and syndesmosis repair and documented a separate diagnosis to support each procedure. I recommended CPT code 27828 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula) and CPT code 27829 (Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed). My surgeon stated he was recently advised that the 2 codes were not reportable together and would not let me submit.

The patient is not Medicare and payor does not follow NCCI edits.

Answer:

Thank you for the thoroughness of your question.
You were correct! Repair of the syndesmosis is not inclusive to the Pilon fracture (27828). Perhaps you can do a corrected claim if it is not too late.
The repair is performed for different medical necessity than the ORIF of the fractures; not all Pilon fractures will have syndesmotic instability.

POS for Hospital Services

Question:

We are wondering if you can help address a discussion in our office related to the coding rule changes for hospital services. CPT instructs to report 99221-99223 (inpatient hospital/observation) and 99231-99223 (subsequent hospital/observation) for both inpatient and observation services. Our hospital does not have a dedicated outpatient observation area; all patients are cared for on the inpatient division. We believe we understand this does not matter for code selection. Here is our question. What is the place of service for the observation patient on the inpatient division now that we are using the same code series?

Answer:

Yes, you understand the guidelines correctly related to the inpatient/observation codes and physical location- it is about admit status in this situation.  You will continue to report the appropriate code from the 99221-99223 and 99231-99233 based on the type of service and the location status of the patient.

If the patient has been admitted as an inpatient, regardless of where there bed is located, you will report the appropriate initial or subsequent hospital inpatient code and the place of service is 21 (Inpatient Hospital).

If the patient is in outpatient observation status (‘admitted’ to observation) you will report the appropriate initial or subsequent observation code and the place of service is 22 (On Campus-Outpatient Hospital (e.g. observation).

POS 19 would not be correct for the patient in observation status as this place of service isOff Campus-Outpatient Hospital.

Is an Annular Repair Separately?

Question:

Our physician stated he was told at his prior hospital that he could report an annular repair with a discectomy.  We have told him this was inclusive but he is asking us to contact KZA.   Is the annular repair reportable in addition to the discectomy code? If yes, what CPT code would we report?

Answer:

Thank you for your inquiry.  Your response was accurate; it is unfortunate when physicians are given inaccurate coding device. While the hospital may be able to bill for closure devices, the work of repairing the annular defect is inclusive to the physicians work. Report the appropriate discectomy codes (e.g. 63020-63030)

Retrocalcaneal Bursectomy

Question:

Our surgeon performed a repair of an Achilles tendon, excision Haglund’s deformity of the calcaneus and retrocalcaneal bursectomy. Are we able to code the bursectomy in addition to the repair and excision of Haglund’s? Thank you in advance for your assistance.

Answer:

Thank you for your inquiry and explanation of procedures performed. The excision of the retrocalcaneal bursectomy is not separately reportable. This work is inclusive to the excision of the Haglund’s deformity.

Shared Visits in the Hospital for Medicare

Question:

I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the level of E&M I recommend?

Answer:

No, the documentation of time is not required if Time will not be a determining factor in E&M code selection.

CMS has delayed the implementation of Time as driver for defining the substantive part of the shared encounter until January 2024.

The following excerpt is from the Final Rule published in November 2022.

Page 212:
“..After consideration of public feedback, we proposed to delay implementation of our definition of the substantive portion as more than half of the total time untilJanuary 1, 2024. We continued to believe it is appropriate to define thesubstantive portion of a split (or shared) service as more than half of the totaltime, and proposed that this policy will be effective beginning January 1, 2024….”

You may consider working with your providers to start documenting time should CMS move forward with a final implementation of Time as the driver of substantive time in 2024. This would allow them to become familiar with including this in their notes, while informational at this time, if the code is to be selected on the MDM and not time..