Documenting Assistant Surgeon

Question:

When acting as an assistant surgeon, should I dictate a separate operative note?

Answer:

No.  In a scenario with a primary and  assistant surgeon, only the primary surgical dictates the operative note. Importantly, in that note, the specific role of the assistant must be documented. This should be more specific then, Dr. Jones assisted in a complex surgery. The specific   activities performed must be documented.

E&M Coding Based on Time

Question:

Our physicians’ defaults to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own independent interpretation of X-Rays (we bill globally), and performs procedures such as nasal endoscopies, debridement’s laryngoscopes etc. in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent. With that said, the activities you identify, because they are billable services represented by other CPT codes (aka are separately reported), do not contribute to the total time spent; this time must be deducted from the total time, assuming the E&M service is reportable.

Modifier Order on CMS Claim Form

Question:

We are submitting a hospital claim form with the modifier 25 and FS modifier. We are unsure which modifier to list first. What is your recommendation?

Answer:

Thanks for contacting KZA and remembering to use the FS modifier for shared services provided in the hospital. KZA recommends placing the modifier 25 first, as this is considered a reimbursement modifier followed by the FS modifier, which is an informational modifier.

Coding for a Laceration Repair

Question:

I repaired a 12 cm jagged laceration of the midabdomen by undermning1cm to release the skin edges. Due to the length of the laceration and potential wound tension concerns, I closed the laceration in layers and retention sutures are used. What procedure code should I report?

Answer:

Good question.  Because Undermining of tissue under skin, retention sutures constitute a complex repair.  Since the defect is 12 cm you would report CPT code 13102 (complex repair of the trunk 2.6 cm to 7.5 cm) plus CPT 13102 (add on code for each additional 5 cm or less).

Gynecomastia

Question:

A 24-year-old male is seen in our office for gynecomastia. My physician did a bilateral resection of the glandular component and liposuction of the fatty components of his defect. I am new to coding for plastic surgery and not sure how to code this. Can you help?

Answer:

Of course. The CPT code reported is 19300-50 (Mastectomy for gynecomastia). Modifier 50 is used when the procedure is performed bilaterally. The diagnosis code to report is N62 (Hypertrophy of the breast).

Diagnosis Coding Help

Question:

I need some guidance. A general surgeon did a left mastectomy four months ago for a patient who had breast cancer. My plastic surgeon did a breast reconstruction yesterday. What diagnosis code do I use?

Answer:

You would report 3 codes, the encounter for breast reconstruction following mastectomy Z42.1, Personal history of breast cancer Z85.3 and Z90.12 for the acquired absence of the left breast.