Forehead Flap

Question:

Our Otolaryngologist routinely does repairs after Mohs surgery. What CPT code do I report for a paramedian forehead flap to reconstruct a nasal defect after Mohs surgery.

Answer:

The correct code to report is CPT code 15731 (Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap).

*This response is based on the best information available as of 01/19/23.

Consultation Coding in 2023

Question:

In 2023, will the level of service be determined by history, exam and medical decision making, or will this change? I have heard it is changing.

Answer:

Beginning January 1, 2023, consultation codes 99242-99255) for both inpatient and outpatient services will be based on medical decision making or time. However, keep in mind a clinically relevant history and clinical examination should also be documented. Also, consultation codes 99241 and 99251 have been deleted.

*This response is based on the best information available as of 12/15/22.

Oral Food Challenge

Question:

What needs to be documented to support billing CPT code 95076/95079?

Answer:

Complete documentation is critical for oral challenges. Be sure to document:

1. Time testing begins and ends
2. The amount of food or drug given
3. Any adverse reactions
4. Discussion of test results

*This response is based on the best information available as of 12/01/22.

Billing an E/M Service on the Same Day as an Oral Food Challenge

Question:

My physician always bills an E/M service with CPT codes 95076/95079.  Is this allowed?

Answer:

It’s rare to bill an E/M code with an oral challenge unless the provider needs to treat for a reaction (intervention therapy – a separate service) or the provider saw the patient for an unrelated office visit the same day as testing.

The office visit cannot be part of the testing and needs to significantly separately identifiable. You cannot double-count the testing time for both the oral challenge and the E/M code! If you do code an E/M visit with an oral challenge, add modifier 25 to the E/M code (99202 – 99215).

*This response is based on the best information available as of 11/17/22.

Nursing Visit on the Same Day as Allergy Injections

Question:

Can you bill a nursing visit when a patient comes in for an allergy injection?

Answer:

The routine preinjection and post injection evaluations by the nurse or MA would be included in codes 95115-95117 and would not be eligible to report separately.

When documentation supports that a significant, separately identifiable evaluation and management (E/M) service was rendered, the appropriate E/M code for the service may be reported. All care directly related to the administration of the injection, i.e., the injection cannot be administered without the preinjection and post injection check by the nurse.

However, if the nurse/MA provided any care unrelated to the injection, then code 99211 may be separately reported with modifier 25. However, such instances would be rare, and documentation would need to support both the service and its medical necessity.

*This response is based on the best information available as of 11/03/22.

Implant vs Foreign Body

Question:

What is the difference between an implant and a foreign body?

Answer:

On page 90 of the Current Procedural Terminology (CPT) Professional Edition 2022, the definition was added to the guidelines. “An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant.  An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”

*This response is based on the best information available as of 10/20/22.