Laser Interstitial Thermal Therapy (LITT) Coding

Question:

I’m using LITT for epilepsy treatment.

Answer:

The codes are 61736Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion and 61737multiple trajectories for multiple or complex lesion(s)

*This response is based on the best information available as of 04/13/23.

Mohs Surgery Question

Question:

We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation.

Answer:

The procedure note for Mohs Surgery should always contain

1. Indication for procedure
2. Biopsy results
3. Location of lesion
4. Number of lesion(s)
5. Size of the lesion(s),
6. Number of stages performed
7. Number of specimens per stage
8. Type of closure

In addition, the first stage must describe the histology of the specimens taken including:
Depth of invasion

1. Pathological pattern
2. Cell morphology
3. Perineural invasion/presence of scar tissue (if applicable)

*This response is based on the best information available as of 04/13/23.

Anterior and Posterior Labral Repairs

Question:

Our surgeon documented anterior inferior labral repairs and then documented posterior inferior repairs.  The surgeon wants to report 29806 x 2 and I do not believe that is correct.  Will you assist?

Answer:

Thank you for your question. You are correct in that CPT code 29806 may not be reported twice. You will report 29806-22 once that includes both labral repairs. Remember to increase your standard fee to signify this code is different than the traditional code (no modifier).

Allergy Treatment Coding

Question:

What CPT code do I use to report a vial test?

Answer:

There is no CPT code, nor should you charge, for a “vial test.” This is part of the vial provision code/activity (e.g., 95165) and not separately reported.

*This response is based on the best information available as of 04/13/23.

Post Op Hemorrhage Repair

Question:

What Modifier do I use when I have to take the patient back to the operating room to repair a post-operative hemorrhage?. My coder told me that complications are included in the payment for the original surgery. But one of my colleagues told me I can bill for the repair during the post-op period.

Answer:

Yes, you may bill for complication that sent the patient back to the OR for the repair. CPT and Medicare agree that taking the patient back to the OR to treat a complication is billable. Modifier 78 (unplanned return to the OR) is appended to the procedure code(s) performed to treat the hemorrhage.

E&M Coding Based on Time

Question:

When choosing the level of E&M we are confused about the History and Exam. If we choose a level of E&M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E&M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (eg, review of tests);
• obtaining and/or reviewing separately obtained history;
• performing a medically appropriate examination and/or evaluation;
• counseling and educating the patient/family/ caregiver;
• ordering medications, tests, or procedures;
• referring and communicating with other health care professionals (when not separately reported);
• documenting clinical information in the electronic or other health record;
• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and
  care coordination (when not separately reported).