Inpatient E/M Coding

Question:

I did an inpatient consultation and coded 99253 (non-Medicare). I did not need to follow the patient so I signed off. They asked me to re-consult a week later. What is the code for a re-consult?

Answer:

There are no specific E/M codes for an inpatient re-consultation. You’ll use the subsequent hospital care code, 9923x, since it’s the same admission for the patient.

Question:Follow up question: the patient was discharged then admitted a month later and I was consulted again. Is this a subsequent hospital care code?

Answer:

No, since it’s a new admission for the patient, you’ll use the consultation code again (9925x).

Question:Last question: when I see the patient in my office a month later, is it a new patient?

Answer:

No, it’s an established patient (9921x) because you’ve had a face-to-face visit with the patient in the previous 3 years.

Nasal Wall Reconstruction

Question:

One of our physicians is scheduling a nasal wall reconstruction with Latera®. He is wanting to use code 30465 (repair nasal vestibular stenosis). I know there is a code for Latera which is 30468 and I feel we should use this code. Please give me your opinion.

Answer:

CPT 30468 was created specifically for procedures such as the Latera implant. It is absolutely incorrect to use 30465 for this procedure.

*This response is based on the best information available as of 12/02/21.

Denial of Breast Reconstruction

Question:

We received a denial for 19357-50 (tissue expander reconstruction) and +15777 x 2 units. The denial reason was “the diagnosis code and CPT code combination is inappropriate”. We used a diagnosis of C50.911 (Malignant neoplasm of unspecified site of right female breast). What diagnosis code(s) should we have used?

Answer:

For breast reconstruction procedures, we typically use the following two diagnosis codes:

Z42.1 Encounter for breast reconstruction after mastectomyZ90.11 or Z90.12 or Z90.13 Acquired absence of right or left or bilateral breast

The cancer diagnosis code, such as C50.911, can be a third diagnosis if the mastectomy was performed on the same day as the reconstruction but we would not use it as a first diagnosis. Your procedure was performed for reconstruction – not to treat cancer. If the reconstruction were performed after the patient has completed all treatment for breast cancer, then you’d use Z85.3 (personal history of breast cancer) as a third diagnosis code.

*This response is based on the best information available as of 08/19/21.

Harvest of Graft for Repair of Nasal Vestibular Stenosis

Question:

We did a septoplasty and repair of nasal vestibular stenosis with spreader grafts using septal cartilage. We billed these codes: 30465, 30520 and 20912. Medicare does not bundle any of these codes. So why did we not get paid on 20912? Should we have used modifier 59 or XS on 20912 to get paid?

Answer:

You were likely not paid on 20912 because harvesting of graft material obtained through the same surgical exposure/incision should not be separately reported. The septal cartilage graft was harvested when you did the septoplasty (30520) which is considered the same surgical exposure/incision. In other words, 20912 is included in 30520. Therefore, you should have only billed 30465 and 30520. Consider yourself lucky that you did not get paid on 20912 because that would have been considered an overpayment for unbundling of codes.

*This response is based on the best information available as of 07/22/21.

Use of Cadaver Cartilage

Question:

We have a patient that needs a major revision rhinoplasty requiring cadaver cartilage. There is no remaining local cartilage that can be utilized in this case and my surgeon has opted to use cadaver instead of rib cartilage. I know local grafts are not separately reportable, but is there a way to bill for cadaver cartilage?

Answer:

Unfortunately, no. The concept is that surgical CPT codes represent physician work. There is negligible physician work in using pre-fabricated cadaver cartilage so that is why a CPT code does not exist.

*This response is based on the best information available as of 07/08/21.

Adjacent Tissue Transfer

Question:

A few years ago I was at your plastic surgery coding workshop in Chicago – you were great, Kim! I remember discussing the adjacent tissue transfer or rearrangement codes and you said we need a size dimension to code for CPT 14040 or 14041 or any of the ATT codes. Do you have a specific guideline or a resource that I can find to support this? As always thank you so much for your guidance.

Answer:

Thank you for your kind words! Sure – just look in the CPT book in the Guidelines for the Adjacent Tissue Transfer or Rearrangement codes. The last paragraph defines the terms primary and secondary defects. The CPT codes themselves are defined by square centimeters – this is the total sq cm of each defect (primary and secondary). When you use a CPT code that has a dimension in the description, such as sq cm or linear cm, then that dimension must be documented to support the billed code. It is very important for you to document the primary defect dimension and secondary defect dimensions separately. These two dimensions are added together to “equal” the CPT code.

*This response is based on the best information available as of 06/24/21.