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Diagnosis Coding Help
Can you please assist with the diagnosis for a Compound Dysplastic Nevi of back?
Question:
Can you please assist with the diagnosis for a Compound Dysplastic Nevi of back?
Biopsy confirmed and not completely excused. Patient comes in for excision of lesion. What diagnosis code should I use?
Answer:
The correct diagnosis code for a dysplastic nevi of the trunk is D22.5 (melanocytic nevi of trunk)
*This response is based on the best information available as of 07/28/22.
Hip Injection
I did a left hip intraarticular steroid injection and used fluoroscopic guidance. Can I report the guidance in addition to the procedure?
Question:
I did a left hip intraarticular steroid injection and used fluoroscopic guidance. Can I report the guidance in addition to the procedure?
Answer:
Yes, you would report CPT code 20610 for the hip injection and 77002-26 for the fluoroscopic guidance. Make certain you use Modifier 26 when performing procedure is a facility setting. Modifier 26 is used for the professional component. Do not report 27093 (Injection procedure for hip arthrography) when reporting CPT 20610.
Billing for Vascular Access
I’m new to vascular coding, can we bill for vascular access for a catheterization? The provider documents this, so I’m thinking I am missing a code.
Question:
I’m new to vascular coding, can we bill for vascular access for a catheterization? The provider documents this, so I’m thinking I am missing a code.
Answer:
No, vascular access itself is not separately billable with a catheterization. However, the provider must document the vessel accessed , what side of the body, RT or LT y, and the end point of the catheter, so the proper catheterization codes can be billed. Remember, some interventions ( cervico-cerebral angiograms, carotid stenting on the same side as the stenting, and more) include catheterization and it would not be separately billable.
2021 Evaluation and Management Codes: Is a History Required?
My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me.
Question:
My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me.
Answer:
You are wise to ask because that’s not exactly true. It is correct that the History will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that you will document a “medically appropriate” (per CPT™ history for each encounter.
*This response is based on the best information available as of 07/28/22.
Removal of Interbody Device
Can code 20680, removal of implant, be used for removal of a previously placed intervertebral device, such as a PEEK cage?
Question:
Can code 20680, removal of implant, be used for removal of a previously placed intervertebral device, such as a PEEK cage?
Answer:
No. There is no code for removal of an intervertebral device – this would be part of an exploration of arthrodesis or new arthrodesis, if performed. Do not use 20680 (removal of implant) for removing spine instrumentation.
*This response is based on the best information available as of 07/28/22.
Coding for Wound Surgical Preparation
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?
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.”
