E/M Level When Patient is Non-compliant With Treatment Advice

Question:

An established patient presents to my office with severe exacerbation of an existing condition, and I recommend they be urgently transferred to the ER for admission. The patient refuses and prefers to leave against my medical advice. May I still bill a level 5 E/M for a high level problem that requires hospitalization and urgent intervention?

Answer:

Yes. If a visit MDM would equate to a level 5 visit (e.g. 99215) based on the presenting problem (severe exacerbation) and risk (urgent admission with intervention), patient non-compliance with a provider’s medical recommendations does not preclude the provider from billing the appropriate level E/M.

*This response is based on the best information available as of 5/8/25.

Need Help Coding Two Dermatology Procedures on the Same Date

Question:

The dermatologist saw a patient in the office yesterday and brought in her pathology report from the family practice doctor. It confirms the cheek lesion is malignant. The physician excised the 1.0 cm cheek lesion and did a simple repair. He also destroyed 3 inflamed seborrheic keratosis with liquid nitrogen on the left hand. What CPT codes should I use?

Answer:

For the 1.0 cm malignant cheek lesion you should report 11641 (excision of malignant skin lesions on the face, ears, eyelids, nose, or lips, with the lesion size ranging from 0.6 to 1.0 centimeters). The simple repair is included in the lesion excision.

For the inflamed SK, you should report 17110 (Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions). You will also need to append Modifier 59 to the destruction code (17110) since it is bundled under the National Correct Coding Initiative (NCCI).

Since the lesion excision is on the cheek and the SKs are on the left hand, the definition of Modifier 59 is met as a separate anatomic area. CPT code 11641 has the higher work RVU’s and should be reported without Modifier 59. CPT 17110 should be reported with Modifier 59.

*This response is based on the best information available as of 5/8/25.

Trigger Finger Release with Tenosynovectomy

Question:

In our practice, we often receive cases where the patient comes in for trigger finger release. Tenosynovitis is also identified after the procedure starts. In addition to performing the trigger finger release, a tenosynovectomy is performed on the involved tendon. Can we report both?

Answer:

Thank you for your inquiry.

According to AAOS Global Service Data, tenolysis or tenosynovectomy is included in procedure code 26055, and any tenolysis or tenosynovectomy would not be separately reported. Additionally, there are NCCI edits between 26055 and 26440 /26442, respectively. The edit may not be bypassed with a modifier.

The intent of the surgery is to release the trigger finger, which would be appropriately reported with CPT 26055.

*This response is based on the best information available as of 5/8/25.

Epistaxis

Question:

If I perform a nasal endoscopy to localize the site of bleed, then remove the scope and use a nasal speculum to cauterize, can I report both 31231 and 30901?

Answer:

You should not report both CPT code 31231 and 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) for this procedure.  CPT code 30901 would be the most appropriate choice for cauterizing a nosebleed. 31231 is a diagnostic procedure and includes the parenthetical statement “separate procedure.” This code is included in a more definitive therapeutic/treatment procedure at the same operative session. Report either CPT code 31231 or 30901, but not both codes.

*This response is based on the best information available as of 5/8/25.

Fall Risk Prevention Program: Part 1

Question:

We want to institute a Fall Risk Prevention Program in our practice to take advantage of CMS's Merit-based Incentive Payment System (MIPS). Based on CMS’s 2024 Quality Measures List, what codes should we report, and can our practice's medical assistant (MA) capture this work? 

Answer:

It is great that your practice will institute a Fall Risk Prevention Program to capture MIPS. According to CMS’s 2024 Quality Measures list, there are 2 measures reportable in this category:

• Quality measure number 155 - Falls: Plan of Care: This measure is designed to capture the percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months. 

• Quality measure number 318 – Falls: Screening for Future Fall Risk: This measure is designed to capture the percentage of patients 65 years of age and older screened for future fall risk during the measurement period. 

Per CPT, these quality measures should be reported with Category II tracking codes, which are used for performance measurement. 

The applicable category II CPT codes for these MIPS measures are as follows: 

• 1100F: Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER). 

• 1101F: Patient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER). 

An MA can capture the work to assist the clinician when reporting these Category II CPT codes. 

*This response is based on the best information available as of 5/8/25.

Costotransversectomy Included in Transthoracic Corpectomy

Question:

Is a costotransversectomy included with non-tumor/lesion transthoracic corpectomies?

Answer:

Yes. A costotransversectomy involves removing a rib or ribs for a thoracic approach to the spine and is always included in transthoracic corpectomy. 

*This response is based on the best information available as of 5/8/25.