Modifiers on Unlisted Codes. Yes or No?

Question:

Can I use modifiers on an unlisted code? What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code.

Answer:

There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers are not appended to an unlisted code.

Payors have their own rules. For example, some payors will accept modifier 62 (two surgeons/co-surgery) on an unlisted code such as 64999 while other payors do not.

We would not append modifier 50 (bilateral procedure) to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22.

We also would not append modifier 51 (multiple procedures) to an unlisted code. Let the payor take the discount.

Coding for Wound Surgical Preparation

Question:

When billing for the muscle flap codes 15733, 15731 etc., can we also code for the surgeon’s cleaning and prepping by debridement before closing the wound with a facial flap?

Answer:

Yes, the surgical prep codes (15002-15005) may be reported with those flap codes as long as the surgical prep service is provided, documented and medically necessary. CPT calls this “surgical preparation” not “debridement.”

Craniosynostosis Co-surgery Question

Question:

We have a new plastic surgeon who will start doing craniosynostosis surgery with a pediatric neurosurgeon. Will this be co-surgery using modifier 62?

Answer:

Potentially yes. It will depend on which surgeon does what part of the procedure. All the craniosynostosis codes (61550 – 61559) accept modifier 62 so if both the plastic surgeon and neurosurgeon do different parts of that CPT code then modifier 62 would be appropriate. If the plastic surgeon does other work such as orbital advancement then the plastic surgeon may separately report that code(s) which might not be co-surgery. It’s going to all depend on the documentation.

E/M Visit During the Global Period

Question:

Can I bill an office visit in the global period if the diagnosis is different from why I did the original procedure?

Answer:

Yes, as long as the diagnosis is not for a related issue (e.g., complication from the original procedure). The documentation must be clear that the condition is unrelated to the original procedure and reflect a clear plan of treatment for the new/unrelated issue. You will then append modifier 24 (unrelated E/M in a global period) to the E/M code.

Skin Lesion Excision – Wait for Pathology?

Question:

I’ve heard you say to wait for the pathology report in order to bill for the skin lesion excision codes 114xx (benign) and 116xx (malignant)? What if I have a biopsy report – do I still need to wait?

Answer:

Good question – no you do not need to wait if you have a biopsy pathology report showing a malignancy for that lesion. You can go ahead and use the malignant diagnosis and CPT codes for the excision.

Bilateral Carpal Tunnel Procedures – Different Days

Question:

We are going to be doing bilateral carpal tunnel procedures on a patient – the right side will be done first then the left will be done 8 weeks later. Should I use modifier 58 (staged procedure) on the 2nd procedure?

Answer:

Actually, it’s best to use modifier 79 (unrelated procedure in a global period) because the left side (2nd procedure) is unrelated to the right side (1st procedure). Be sure to use the laterality specific ICD-10-CM codes – G56.01 (Carpal tunnel syndrome, right upper limb) and G56.02 (Carpal tunnel syndrome, left upper limb) – for the respective procedures.