Postoperative Incision Drainage

Question:

A patient had bilateral breast augmentation 5 weeks ago. She developed some drainage out of the lateral aspect of her left breast inframammary incision. The area was probed in the office with a Q-tip and it communicated with the implant pocket so I did a wash out of the left breast and replacement of the implant. We are charging the patient, not the insurance company, and my coder wants to use 19328 for the implant removal, 10060 for the washout, and 19325 for the new implant placement to determine our fee. I think my coder is unbundling and I should only charge my fee for 19325. What are your thoughts?

Answer:

I agree with you to use only 19325 for your fee comparison. The removal (19328) is included in the new placement (19325) because you couldn’t put a new implant in unless the old one was removed. Also, the wound washout would not be separately reported.

*This response is based on the best information available as of 10/31/19.

Removal of Breast Implant with Capsulectomy

Question:

My doctor specializes in breast reconstruction and has been asking me to bill 19328 (removal of intact breast implant) along with 19371 (capsulectomy) when he has to do a capsulectomy and remove the implant. It has come to my attention that this may be wrong and that 19328 is included in 19371. The CPT book is unclear and there is not a National Correct Coding Initiative (NCCI) edit between these two codes. So can I bill both?

Answer:

This is great example of where Medicare’s NCCI edits don’t reflect accurate coding. A CPT Assistant newsletter states “A capsulectomy (CPT code 19371) involves removal of the capsule. The implant is also removed and may or may not be replaced.” Therefore, CPT 19370 (capsulotomy) is included in 19328 when performed to remove the implant. CPT 19371 (capsulectomy) includes 19328 so both codes would never be reported for the same breast.

*This response is based on the best information available as of 10/17/19.

Division and Inset of Flap

Question:

A patient presents for division and inset of a neck-to-ear pedicle flap.  Should we report 15620 or 15630?

Answer:

The CPT codes reported for the division and inset are chosen by the permanent inset site, not the donor site.  So in your case, CPT code 15630 (Delay of flap or sectioning of flap at eyelids, nose,ears, or lips) would be reported, not 15620 (Delay of flap or sectioning of flap at forehead, cheeks, chin,neck, axillae, genitalia, hands, or feet).

*This response is based on the best information available as of 07/25/19.

Sentinel Node Identification

Question:

We have a new plastic surgeon and he’s doing a procedure my other guys don’t perform.  The patient goes to radiology for injection of radioactive isotopes then to the operating room where my plastic surgeon excises the skin cancer and then injects blue dye and uses a gamma probe to identify a sentinel node.  Then he excises the sentinel node.  I’ve never coded lymph node procedures before – help!

Answer:

It’s always fun to learn something new, isn’t it!  For the lymph node removal procedure, look at codes 38500 – 38531 to see which code best matches the procedure he did.  Then you can also report +38900 (Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)). CPT +38900 covers the intraoperative injection and use of the gamma probe to identify the sentinel lymph node.

*This response is based on the best information available as of 3/28/19.

Botox for Migraine Headaches

Question:

When you inject Botox for migraine headaches, can you bill the injection code more than one time? We normally go about this as a cosmetic procedure, but I just wanted to look into this to see if I could bill out CPT code 64615 for each muscle group that is injected?

Answer:

The CPT language is very clear that all four muscle groups, on both sides, must be injected for a total of 8 injections. CPT 64615 states Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine).  In your scenario, you will use 64615 and bill as 1 unit.

*This response is based on the best information available as of 3/14/19.

Diagnosis Code for Post Op Visits

Question:

What’s the best way to do the diagnosis coding for postop visits? I mean, does it really matter since we aren’t billing for a visit?

Answer:

Yes, it is important to accurately code the diagnosis. The ICD-10-CM guidelines for postop/aftercare include the following:

1. If the original diagnosis is trauma (eg, using an S diagnosis code)ora code that requires a 7^thcharacter (eg, M80-): then you’ll continue to use the original diagnosis code but you’ll change the 7^thcharacter to one which includes “subsequent encounter”.  For example, a finger fracture – when you fixed the fracture in surgery you used a diagnosis code with a 7th character of, say, A (initial encounter, closed fracture).  So for your postop visits (CPT 99024), you’ll use the same finger fracture diagnosis code but with a 7^thcharacter of, say, D (subsequent encounter, routine healing).

2. For non-trauma diagnoses (and those that do not require a 7^thcharacter): Now you’ll switch to a Z code when you’re using CPT 99024.  Look at the Z48.- codes…there are several that can be used such as:

Z48.00   Encounter for change or removal of nonsurgical wound dressing

Z48.01   Encounter for change or removal of surgical wound dressing

Z48.02   Encounter for removal of sutures (or staples)

Z48.03   Encounter for removal of drains

*This response is based on the best information available as of 1/31/19.