Coding For Arthroscopic Subacromial Decompression

Question:

We received a denial from one of our payors saying the documentation did not support CPT code 29286. The surgeon documented bursectomy, release of ligament and removal of anterior osteophytes. Does this support CPT code 29826? 

Answer:

Thank you for your inquiry. Unfortunately, the payor is correct. The removal of osteophytes with or without the bursectomy and ligament release does not support CPT code 29826. To report the subacromial decompression, documentation must support an acromioplasty, which is a reshaping of the acromion. Typically, surgeons will document the work and state they took the acromion from a Type III to a Type I.  

*This response is based on the best information available as of 7/11/24.

CPT and ICD-10-CM Codes in Operative Notes

Question:

What is KZA’s perspective when a surgeon documents the CPT codes within the clinical operative note? 

Answer:

KZA discourages using CPT and ICD 10 codes within the operative notes. While documenting details of each procedure is key within the operative report (both the header and within the body of the note), adding CPT and ICD 10 diagnosis codes creates an issue if the coding is incorrect. The operative report is part of the legal medical record, and payors may question the accuracy and validity of the entire report if the codes documented within the record are different than the codes billed. For this reason, we advise against documenting the specific CPT and ICD 10 codes within the operative report to prevent other denial and stall tactics. 

*This response is based on the best information available as of 6/20/24.

Assistants at Surgery

Question:

We have surgeons who use their “Fellows” per their program as “Assistants at Surgery” and want to bill the corresponding codes under the “Fellow” with the “80” modifier. Is this OK?  

Answer:

Under the current CMS guidelines, fellows are considered residents when practicing within their GME program, so their services as surgical assistants would not be billable. However, there are certain circumstances where a fellow may bill for their own services when practicing outside their GME program (e.g., in the Emergency Department, seeing patients as a primary physician (not in an orthopedic capacity). A Fellow in a private Fellowship and employed by the group practice is billable as a Fellow. These are non-GME-funded fellowships. 

 In an academic setting, we suggest that questions regarding fellow reporting be referred to Compliance for discussion and direction. CMS has very specific guidelines regarding moonlighting that can be found here: https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf 

*This response is based on the best information available as of 6/6/24.

Intradiscal Steroid Injection

Question:

Is there a CPT code for an intradiscal steroid injection for “discogenic pain?”   

Answer:

There is no CPT code for an intradiscal steroid injection. You will report an unlisted code, 22899 or 64999. Most payors consider non-thermal glucocorticoid injections as not medically necessary. Follow your payor policies for reporting unlisted procedures and procedures that may be denied as not medically necessary.  

*This response is based on the best information available as of 5/23/24.

Orthotic Management Codes with Fitting and Adjustment HCPCS code

Question:

We recently hired a physical therapist to allow patients to receive therapy in our office if they wish. We have never coded for therapy services prior to his arriving and are unsure if his recommended CPT codes are correct.  

The therapy service will be provided on the same day as the physician’s E&M service.  

The physician wrote an order for physical therapy and a knee orthotic with locking knee joints, prefabricated, and will bill HCPCS Code L1831 with an E&M code in addition to physical therapy.  

The therapist suggested CPT codes are: 

97162 (Initial physical therapy evaluation, moderate complexity) 

97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minute) 

We are not questioning the accuracy of CPT code 97162 but seeking guidance on CPT code 97760. 

Answer:

Thank you for your inquiry to KZA. You are correct to question the accuracy of reporting the orthotic management codes with this specific DME L code. 

HCPCS code L1831 is defined as “Knee orthosis (KO), locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment” The inclusion of “fitting and adjustment” in the code descriptor precludes reporting 97760 as this would define overlap between the valuation of the L code and CPT code 97760; both include fitting in their definitions.  

Remember to append modifier 25 on the therapist evaluation CPT code to show the significant separate service rules were met (differentiation between physician E&M service and therapist evaluation code).  

*This response is based on the best information available as of 4/25/24.

Time

Question:

Our physician is coding by time; he thinks this is the best for him.  Frequently with a new patient he will also do an injection.  He documents his total time for the day but does not document the amount of time performing a minor procedure (billable).  There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?  

Answer:

CPT states “Time” may be selected based on the total amount of time spent on the date of encounter, excluding time spent for services that are defined by a separately reportable CPT code.  This means that the total time must exclude the amount of time spent related to the minor procedure.  If not documented, KZA recommends asking the physician to amend the note if possible (attesting that the time is accurate to the best of their knowledge) or reporting the service based on MDM.  

*This response is based on the best information available as of 4/11/24.