Gender Reassignment “Top” Surgery Coding

Question:

We are having a debate on whether to use a mastectomy code or breast reduction code for “top” female-to-male procedures. What’s your advice?

Answer:

Unfortunately, we do not have a specific CPT code(s) for these procedures as the existing codes were not written with these procedures in mind. Our advice is to consult the payor’s medical coverage policy and determine the payor’s preference for how to code for the procedure you’re performing.

Level 5 Office E/M Code

Question:

I was told that if I recommend surgery then I can automatically bill 99205 or 99215. This seems too good to be true. Please advise.

Answer:

You’re right – you’ve been given inaccurate information. Remember, office visit codes (99202 – 99205, 99212 – 99215) require meeting or exceeding two of the three Medical Decision Making elements. The third element, Risk, is where recommending surgery is relevant. You still need to meet one of the remaining two elements – Problems Addressed or Data – to get to the level 5 codes which require high Problems Addressed, extensive Data, and high Risk.

Capsulectomy with Breast Reconstruction Implant Exchange

Question:

We billed 19371 (capsulectomy) with a breast reconstruction implant exchange (19342 – larger to smaller). We were denied 19371. Should we have used modifier 59 on 19371 to get paid?

Answer:

This Medicare National Correct Coding Initiative (NCCI) edit is a dilemma. CPT implies that you are allowed to use both codes – 19342 and 19371 (or even 19342 and 19370) – but Medicare won’t pay both codes. It would not be accurate to bypass the NCCI edit with modifier 59 when the procedures are performed on the same side. Modifier 59 may be used when the procedures are performed on different sides.

Closing the Partial Mastectomy Wound

Question:

A patient has a partial mastectomy by a general surgeon. After the surgery, a plastic surgeon comes in to close due to possible reconstruction. The plastic surgeon ends up only doing a layered closure. A layered closure is inclusive the in the partial mastectomy (19301) but is the plastic surgeon still able to get credit for the layered closure (12034) because she is a different specialty?

Answer:

In our experience, no, the plastic surgeon would not be reimbursed for a simple, intermediate or complex repair code in this situation. Sorry. Good question though!

Nasal Fracture Denial

Question:

We precertified and billed a nasal fracture CPT code. The payor requested the operative note which we sent. The payor then denied the procedure and said we didn’t bill the right code. I don’t understand.

Answer:

After reading the operative note you sent, I understand the denial. The Indications said the patient had a “history of nasal fracture” and did not say the fracture was acute. The surgeon also had to do osteotomies to mobilize the nasal bones because the fracture had healed. Therefore, this procedure is considered a rhinoplasty and not a nasal fracture repair.

Billing Additional Pre-op Visit

Question:

Since we have to bring the patients back in for COVID testing and H&P for Joint Commission, can we bill for this visit even though it’s another pre-op visit?

Answer:

Yes, the original surgery was canceled and is now under consideration for rescheduling due to the pandemic and the patient needs to be seen for a COVID swab prior to surgery. This health status change is the indication for the office visit.