Counting Problems Addressed for Medical Decision Making

Question:

If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?

Answer:

No, sorry, unfortunately it does not work that way. The problems are no additive or cumulative. One stable chronic illness and one acute uncomplicated illness without systemic symptoms is still Low Problems Addressed.

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.

Coding a Discectomy with a Posterior Lumbar Interbody Fusion

Question:

Can we code a laminectomy for disc herniation, such as 63030 or 63042, with a TLIF/PLIF code (22630, 22633)?

Answer:

Good question! There was an update in CPT 2022 to this very complicated and lengthy issue. No – a discectomy may not be separately reported (e.g., 63030, 63042, 63056) since it is required for the posterior lumbar interbody fusion. However, there are new codes – +63052 and +63053 – that may be separately reported when a unilateral or bilateral laminectomy/facetectomy/foraminotomy for decompression is performed. Learn more from our recent 2022 CPT Update for Spine Surgery webinar here:https://karenzupko.com/2022-cpt-update-for-spine-surgery/

*This response is based on the best information available as of 02/24/22.

2021 E/M Guidelines MDM Table

Question:

We are using the 2021 E/M guidelines in the office and in most cases base the level of service on medical decision making.  If I have a patient with a chronic condition that is stable who also has diabetes in which the Internist (nor our specialty) is managing, can I assume the number and complexity of problems addressed is moderate since I have 2 diagnoses?

Answer:

If the physician is not managing the diabetes, it cannot be counted toward complexity of problems addressed. In this situation since the chronic condition is stable it equated to low for the element. Keep in mind you also have two other elements for medical decision making; amount of and/or complexity of data to be review and risk of complications and/or morbidity of patient management. Two of three elements must be met to support the level of medical decision making.

*This response is based on the best information available as of 02/24/22.

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 02/24/22.

Coding a Discectomy with a Posterior Lumbar Interbody Fusion

Question:

Can we code a laminectomy for disc herniation, such as 63030 or 63042, with a TLIF/PLIF code (22630, 22633)?

Answer:

Good question! There was an update in CPT 2022 to this very complicated and lengthy issue. No – a discectomy may not be separately reported (e.g., 63030, 63042, 63056) since it is required for the posterior lumbar interbody fusion. However, there are new codes – +63052 and +63053 – that may be separately reported when a unilateral or bilateral laminectomy/facetectomy/foraminotomy for decompression is performed. Learn more from our recent 2022 CPT Update for Spine Surgery webinarhere.