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. For example, Dr. Jones assisted with the exposure, vessel clamping , anastomoses of the inflow and outflow vessels.

Internal Brace for ACL Reconstruction

Question:

We have a surgeon who is planning to perform an ACL procedure using the InternalBrace TM Technique. The surgeon is asking if she would still report CPT code 29888, use a modifier 52, or an unlisted code. Are you able to advise? I do not have an operative note to send.

Answer:

Thank you for your inquiry and recognizing we are not able to provide definitive coding advice without an operative note.  This is a good question.

In this case, based on your inquiry, let your surgeon know she will report CPT code 29888 without any modifiers.   The CPT code statesrepair/augmentation or reconstruction.   Please share with your surgeon KZA appreciates her due diligence in her planning process.

Billing a Right Colectomy with a Diverting Loop Ileostomy

Question:

How is a right colectomy with a loop ileostomy reported?

Answer:

A loop ileostomy with a right colectomy is reported with 44160 (open) or 44205 (laparoscopic) and creation of an ileostomy; code 44130 (open) or code 44187 laparoscopic. This reflects the additional work of creating the external opening; the ileostomy.

Source: ACS Bulletin November 2019

*This response is based on the best information available as of 07/20/23.

Allergy Testing Help

Question:

What is the daily maximum allowable unit for CPT 95017 [Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests] by Medicare in 2023?

Answer:

The MUE’s (medically unlikely edits) for 2023 IS 27.

*This response is based on the best information available as of 07/20/23.

Placement of Percutaneous Posterior Instrumentation (Rod and Screws) Part 1

Question:

I placed posterior percutaneous screws and rods without an arthrodesis, the day after an ALIF. Should I bill 22842, it was segmental, 3-6 segments spanned, and a 58 modifier?

Answer:

Code 22842 is for open segmental instrumentation. Most importantly, it is an add-on code and can only be reported with a parent or primary code, such as the ALIF code 22558. Without a primary code, the percutaneous placement of rods and screws must be reported with an unlisted code 22899.

*This response is based on the best information available as of 07/20/23.

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).