Denials for Initial Hospital Care and Observation E/M Codes: 2024

Question:

We are experiencing denials when we bill 99221-99223 and the place of service is observation (outpatient hospital).  Are we doing something wrong?

Answer:

You are billing correctly based on CPT 2023 guidelines for E/M that merged inpatient hospital encounters/codes with observation encounters/codes.  Unfortunately, some payor claims processing systems may not yet recognize these changes as they apply to billing.  You will have to appeal these denied claims, with CPT references showing the current guidelines for E/M reporting. 

*This response is based on the best information available as of 2/15/24.

Billing Ultrasound Guidance with Cranial Tumors

Question:

My surgeon uses ultrasound to facilitate locating lesions in the brain and wants to bill 76998-26 for imaging. Is this appropriate? 

Answer:

No, ultrasound to locate a lesion and/or to confirm adequate resection is included in n the primary procedure and not separately billed 

*This response is based on the best information available as of 2/15/24.

Modifiers with Unlisted Codes

Question:

Can I use modifiers on an unlisted code?

Answer:

In some circumstances, a modifier may be appropriately appended to an unlisted code.

For example,

• CPT says, while uncommon, if multiple separately reportable unlisted codes are performed on the same patient on the same date by the same physician, multiple unlisted codes may be reported. If the two procedures are performed in the same anatomic region, then multiple units of the unlisted code may be reported with a modifier 59

• Modifier 62 (two surgeons/co-surgery) may also be appended to an unlisted code such as 64999 if co-surgery is documented.

• Modifier 58 for staged or more extensive procedures may also be appended to alert the payor to a second surgery during the global period,

• During the global period, it may also be appropriate (and recommended) to append global period modifiers such as 78 or 79 to an unlisted code to fully describe the surgical scenario to a payor.

Do not append modifier 50 (bilateral procedure), modifier 51 or modifier 52 or 53 to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22.

*This response is based on the best information available as of 2/1/24.

Intracranial Cerebral Venogram

Question:

How is an Intracranial cerebral venogram coded?

Answer:

Venous catheterization, with the catheter advanced into the intracanal venous circulation, is reported with code 36012, second order venous catheterization.  The venous imaging is typically a superior sagittal sinus venogram, 75780.

*This response is based on the best information available as of 2/1/24.

Coding Question on a Diagnosis

Question:

What is Actinic Keratosis and what procedure is used to treat this condition?

Answer:

Actinic Keratoses is an extremely common dermatological condition among the elderly. It is suspected to be a pre-malignant condition. The condition presents as rough, sometimes red, scaly patches on the skin, typically where there has been exposure from the sun. Common areas are the face, scalp, neck, ears, forearms, and hands. While they are mostly benign lesions, most squamous cell carcinomas begin as actinic keratoses, making it preferable to remove or destroy them before it can progress into malignancy. Treatment for Actinic Keratoses is cryotherapy which is a destruction.

The procedure to destroy or remove actinic keratoses are generally covered by Medicare and commercial payers. The CPT code to report actinic keratosis destruction is 17000 for the first lesion, 17003 for the second through 14th lesions (each lesion) and 17004 for 15 lesions or more and is reported only once. The diagnosis code for Actinic Keratosis is L57.0.

*This response is based on the best information available as of 2/1/24.

Coding Laparoscopic Liver Biopsy

Question:

How is a laparoscopic biopsy of the liver reported. Can we use code 47001, Biopsy of liver?

Answer:

47001 Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for primary procedure) may only be reported with an open procedure. See CPT Assistant 1992 below. If a laparoscopic biopsy of the liver is performed at the same time as another laparoscopic procedure, for example a laparoscopic cholecystectomy, report an unlisted code (47379). There is no CPT code for a laparoscopic liver biopsy.

*This response is based on the best information available as of 2/1/24.