92504 Binocular Microscopy

Question:

I used the microscope to examine both ears during an office visit because the middle ear Otoscopic exam was abnormal.  Can I report 92504 with modifier 50 (bilateral procedures)?

Answer:

No.  CPT 92504 describes using a microscope for an examination – it represents payment for using a separate piece of equipment for your exam.  The code is not reported twice, nor is modifier 50 appended, when both ears are examined.

*This response is based on the best information available as of 12/14/17.

Billing for Pre-Op H&P Visit

Question:

Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer:

No, the H&P in this case is not a billable visit.  This question comes up often and was addressed by AMA CPT Assistant in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional Question:s. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT says once the decision is made to proceed with surgery the subsequent visits related to the procedure (e.g., doing H&P, getting consent form signed, answering Question:s) are included.  However, in some cases a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease and asthma) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery.  This visit can be billed as an E&M visit as the decision for surgery is just now being made.

*This response is based on the best information available as of 07/13/17.

Total Thyroidectomy and Reimplantation of Parathyroids

Question:

My doctor did a total thyroidectomy and reimplanted one of the parathyroid glands into the sternocleidomastoid muscle. Can I code 60512 in addition to 60240?

Answer:

CPT 60240 for the total thyroidectomy is correct. However, if one or more of the parathyroid glands is reimplanted in the same surgical exposure (e.g., SCM muscle) then it is not accurate to separately code +60512. The reimplantation should be done through a separate surgical approach/incision for +60512.

*This response is based on the best information available as of 05/25/17.

Septal Cartilage Graft and Septoplasty

Question:

My doctor did a septoplasty, CPT 30520, removed cartilage and fashioned it for a graft that he used in the surgical repair of vestibular stenosis, CPT 30465. Can we also code 20912 for the fashioning of the graft or just 30520 and 30465? I couldn’t find any CCI edits preventing this.

Answer:

Only one code, 30520 or 20912, may be reported as these procedures were performed through the same incision. What was the reason for the incision – to straighten the septum (30520) or to obtain the graft (20912)? Use whichever code is supported by the documentation but do not use both codes. .

*This response is based on the best information available as of 02/02/17.

Excisional Biopsy

Question:

My doctor’s documentation for a biopsy indicates he performed an “excisional biopsy of the skin”. Is this correct?

Answer:

No, CPT does not have a code for excisional biopsy. It is either a biopsy (11100 or 11101) or a benign or malignant excision code. (114xx, 116xx). It is important to use the appropriate terminology in the documentation to make it clear what type of procedure is performed. It is important to remember that all excision codes include a biopsy.

*This response is based on the best information available as of 01/19/17.

Pharyngoplasty With Free Flap Reconstruction

Question:

I’m doing the repair of the oral cavity defect with a free flap reconstruction after the head and neck surgeon has resected the cancer. Can I code both 42950 and the free flap code such as 15758?

Answer:

The free flap codes include the harvest, inset, microvascular anastomosis, and closure of both donor and recipient site defects. You may separately code the harvest of graft material through a separate incision (e.g., split thickness skin graft) to facilitate the donor defect closure. So the answer is no, it is not accurate to separately code for a pharyngoplasty when you are insetting the free flap.

A CPT Assistant article from April 2016 addresses this situation in great detail.

Question:

Is code 42950, Pharyngoplasty (plastic or reconstructive operation on pharynx), reportable in addition to code 15757, Free skin flap with microvascular anastomosis, when a free flap is used to reconstruct both a neck and tongue defect (after laryngectomy or glossectomy)? The microvascular free flap is de-epithelialized and the skin paddle is used to complete the pharyngeal closure. The rest of the flap is used to complete the esophageal closure.

Answer:

No, CPT code 42950 should not be reported in addition to code 15757, when a free flap is used to reconstruct both a neck and tongue defect (after laryngectomy or glossectomy). The intraservice work of code 42950 is encompassed in code 15757, which includes harvesting a donor free flap, insetting the free flap at the recipient site using microsurgical technique, and closure of both donor and recipient sites. The pharyngeal reconstruction should be included in code 15757, as it would for wherever the flap was inserted. In addition, the inclusion of the flap closure should be considered as part of the work included in the basic closure of the primary resection site. This basic closure is inclusive of code 15757.

*This response is based on the best information available as of 12/15/16.