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Kyphoplasty Coding
How do you report a kyphoplasty at 2 different spine regions, for example at T12 and L1?
Question:
How do you report a kyphoplasty at 2 different spine regions, for example at T12 and L1?
Answer:
Use one primary procedure code and an add-on code for additional levels even when crossing spinal regions. Example: T12 and L1 kyphoplasty is reported using 22513 and +22515,not22513 and 22514.
*This response is based on the best information available as of 11/30/23.
Time
Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?
Question:
Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?
Answer:
CPT states “Time” may be selected based on the total amount of time spent on the date of encounter, excluding time spent for services that are defined by a separately reportable CPT code. This means that the total time must exclude the amount of time spent related to the minor procedure. If not documented, KZA recommends asking the physician to amend the note if possible (attesting that the time is accurate to the best of their knowledge) or reporting the service based on MDM.
*This response is based on the best information available as of 11/30/23.
Date of Service
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Question:
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Answer:
The correct date of service is the actual date of service when the attending physician saw the patient. In this case, it will be Wednesday even if the attending physician links the note to the resident note from the previous date.
*This response is based on the best information available as of 11/30/23.
Appendectomy with Cecum Resection
As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy?
Question:
As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy?
Answer:
No, that resection is considered part of the appendectomy procedure and not separately reported.
*This response is based on the best information available as of 11/30/23.
Time Reporting for E/M Levels
My physician is billing office visits 99202-99215 based on time only. Is this best practice?
Question:
My physician is billing office visits 99202-99215 based on time only. Is this best practice?
Answer:
The E/M services 99202-99205 are based on either medical decision making or time.. Practitioners may choose to either bill by time or medical decision making. The practitioner should evaluate each patient encounter to determine which method is more advantageous. If time is used to calculate the E/M service, the total time should include all work associated with the patient encounter on the date of service. KZA recommends that the practitioner document an attestation statement itemizing the time spent on the specific activities for the patient. Example:. “This encounter took 45 minutes of time including taking a history, performing the examination, reviewing the CT scan, reviewing the PCP’s notes, counseling the patient on the conditions treated formulating a plan of care as well as documenting in the EHR.”
Established Patient: New Injury and Injection
We have a major hip and knee practice. We frequently see patients back for repeat injections; typically, we do not report the E&M, and report the injection only.
Question:
We have a major hip and knee practice. We frequently see patients back for repeat injections; typically, we do not report the E&M, and report the injection only.
Recently, in one of our coding meetings, we discussed “well, what if the patient presents with a new injury and the physician re-injects the same joint.”
The scenario the team created was as follows:
Established patient, prior knee injections, presents for unplanned visit with a new twisting injury sustained when the patient tripped over a rock while trail hiking. The injury caused the patient to lose balance and fall into a tree. The patient presents with complaints of the twisting injury, knee swelling and bruising in the area. The physician will order X-Rays. After reviewing the physician aspirates and injects the joint.
Does this meet modifier 25? We have not typically billed for this type of encounter and are trying to decide if we\ are too conservative in our approach.
Answer:
KZA appreciates the coding team meeting to discuss issues, concern about accurately reporting modifier 25 or not, and the detailed scenario.
KZA recommends reporting the E&M and an aspiration/injection in your scenario. There is a new injury requiring the physician to perform a medically appropriate exam and the decision to order X-Rays. The work is not related to a “repeat” injection but is medically necessary to evaluate the new injury. The physician will have an injury diagnosis, possible effusion diagnosis since an aspiration was performed and the diagnosis for any underlying condition if the fall caused an exacerbation of the underlying condition.
