Knee Ligament Repair vs Reconstruction

Question:

What type of graft or fixation material is required to report open extra-articular knee ligament reconstruction code 27427? Our physician is listing “MCL repair” and “MCL reconstruction” within the same operative note. It first describes repair of the ligament using Suture Tape. In a separate paragraph the physician describes insertion of additional Tape, but calls the work “reconstruction”.

Answer:

Reconstruction CPT codes are used when biologic tissue is used to replace insufficient, nonfunctioning, or missing native tissue. The replacement biologic tissue may be an autograft (harvested from the patient) or an allograft (harvested from a cadaver). In this example the physician is using additional Suture Tape to supplement or protect the repair; that is not considered reconstruction.

Re-exploration Laminectomy Billing

Question:

The patient had a re-do laminectomy for stenosis at L3-L4. Can code 63042 be used for this procedure?

Answer:
No. CPT 63042 is intended for a re-do discectomy and would be inappropriate to use for a re-do laminectomy. Rather, use 63047 for this service and modifier 22 may be appended if significant additional work is documented.

*This response is based on the best information available as of 06/16/22.

Billing for Intestinal Tear During Enterostomy Closure

Question:

While performing a cholecystectomy a tear in the small bowel was made during extensive lysis of adhesions. Can repair of this injury be billed in addition to the cholecystectomy? It was unavoidable since it was the consequence of the extensive lysis required?

Answer:

Although the tear was unavoidable, the repair would not be separately billing. It is still be considered an iatrogenic (inadvertent or accidental) procedure.

However, if documentation supports the increased difficulty during the procedure (including documentation of time spent in addition to the usual time for the procedure), then a modifier 22 may be indicated.

*This response is based on the best information available as of 06/16/22.

Billing Code 34713, Using a 12 French or Larger Catheter with EVAR

Question:

I almost always use a 12 French or larger catheter for placing the main body for EVAR. Do I always bill the new code 34713, when what I use is a 12 French or larger?

Answer:

Yes, if your approach/exposure is percutaneous. CPT code +34713,Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath ( 12 French or larger), including ultrasound guidance, when performed, unilateral,is only appropriate when the access is percutaneous. If you do an open exposure and use a 12 French or larger catheter, code 34713 would not be reported.

For more detailed information on coding the new EVAR code set, please contact us for a consultation.

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.

Incident-to Requirements for Medicare

Question:

Thank you so much for all the information you gave out in Chicago at the KZA Convention. We always have great take-a-ways when we leave there. I do have a question for you regarding incident-to billing for Medicare.

One of my physicians is stating that her attorney told her being “under the same roof” of the building counts and you don’t necessarily need to be in the same suite. I am disagreeing stating they have to be in the same suite and even though she is available to run upstairs if needed, by her being on the second floor that goes against the “incident-to” rules. Am I correct?

Answer:

According to CMS In order to qualify as an incident-to service, there must be direct physician supervision of the NPP providing the service. Direct supervision means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. It does not mean that the supervising physician must be present in the room where the procedure is performed. Also the supervising physician must be immediately available (without delay). The supervising physician can be in another room As long as they are not performing a procedure that they cannot stop and go to help with the other patient then they are considered immediately available. CMS also clarifies that immediately available

CMS has clarified the office suite it is limited to the dedicated area or suite designated by records of ownership, rents, or other agreements with the owner.

Sources:https://med.noridianmedicare.com/web/jeb/topics/incident-to-servicesand CMS Medicare Benefit Policy Manual Pub. 100-2, Section 60https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

*This response is based on the best information available as of 06/16/22.