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Biopsy of Ear
What CPT code should I report for an excisional biopsy of the external ear?
Question:
What CPT code should I report for an excisional biopsy of the external ear?
Answer:
The correct code to use is 69100.
*This response is based on the best information available as of 4/25/24.
Post Operative Infection
What CPT code would I use for an I&D of a complicated postoperative wound infection?
Question:
What CPT code would I use for an I&D of a complicated postoperative wound infection?
Answer:
The correct CPT code is 10180 (Incision and drainage, complex postoperative wound infection).
*This response is based on the best information available as of 4/11/24.
Submucosal Repair with Lateral Wall Implants
What code do I use for a unilateral repair of a nasal valve collapse with submucosal wall implants on one side?
Question:
What code do I use for a unilateral repair of a nasal valve collapse with submucosal wall implants on one side?
Answer:
You would report CPT code 30468 (Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)). You will need to append Modifier 52 (reduced services) to 30468 since the procedure was performed unilaterally, and CPT code 30468 is a bilateral procedure.
*This response is based on the best information available as of 3/28/24.
Thyroidectomy
I did a right thyroidectomy 10 days ago and used CPT code 60220. I sent the specimen for analysis. The pathology came back positive for thyroid cancer, and I had to perform a completion thyroidectomy on the left. How would I code this? Do I code the thyroidectomy code again 60220?
Question:
I did a right thyroidectomy 10 days ago and used CPT code 60220. I sent the specimen for analysis. The pathology came back positive for thyroid cancer, and I had to perform a completion thyroidectomy on the left. How would I code this? Do I code the thyroidectomy code again 60220?
Answer:
You could code a completion thyroidectomy CPT 60260 (thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid). Ensure you also append Modifier 58 (staged or related procedure) since you are within the global 90-day period.
*This response is based on the best information available as of 3/14/24.
Tongue Lesion Excision
My physician always bills a glossectomy CPT code 41120 when removing a lesion from the tongue. Is this correct?
Question:
My physician always bills a glossectomy CPT code 41120 when removing a lesion from the tongue. Is this correct?
Answer:
No this is not correct. The glossectomy codes require the removal of a portion or all of the tongue. When a lesion is removed report a code from CPT 41112-41114.
*This response is based on the best information available as of 2/29/24.
Time
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?
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 12/14/23.
