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Breast Biopsies on Both Breasts – Same Session
Our breast surgeon performed biopsies (with a clip) on both the right and left breasts using ultrasound imaging. Do we code 19083 x 2 units since they are different breasts, or would we use 19083 and 19084 as the add-on code?
Question:
Our breast surgeon performed biopsies (with a clip) on both the right and left breasts using ultrasound imaging. Do we code 19083 x 2 units since they are different breasts, or would we use 19083 and 19084 as the add-on code?
Answer:
If additional lesions (as you have described above) are biopsied in the contralateral breast using the same imaging, report the primary code and the add-on code for the second lesion. If more than one lesion is biopsied, using different imaging modalities, report the appropriate primary code for each.
*This response is based on the best information available as of 4/11/24.
Billing an Extremity Angiogram with a Neuroendovascular Procedure
Our endovascular surgeons image the radial artery at the beginning of the procedure ( an initial run) to ensure that the artery is healthy/ in good shape to move forward with the procedure. They do not begin the actual procedure without ensuring the radial artery is normal. They also perform imaging as they complete the procedure (on the way out) to assess for any damage to the artery. Is this separately billable as 75710, imaging of a peripheral artery?
Question:
Our endovascular surgeons image the radial artery at the beginning of the procedure ( an initial run) to ensure that the artery is healthy/ in good shape to move forward with the procedure. They do not begin the actual procedure without ensuring the radial artery is normal. They also perform imaging as they complete the procedure (on the way out) to assess for any damage to the artery. Is this separately billable as 75710, imaging of a peripheral artery?
Answer:
Imaging of the access artery (radial or femoral) whether to assess patency of the access artery or as a completion study, checking to make sure no damage has been done to the access vessels is never billed separately. Accessing a vessel is the approach for an endovascular procedures and is included in the primary procedure. Furthermore, although not the primary reason for not billing, there is no pathology to support the medical necessity of an extremity angiogram and that code requires imaging and documentation of a full extremity study; the entire arm, not just a single peripheral vessel.
*This response is based on the best information available as of 3/28/24.
Biopsy of Eyelid
Can I use CPT code 11106 for an incisional biopsy of the eyelid?
Question:
Can I use CPT code 11106 for an incisional biopsy of the eyelid?
Answer:
An incisional biopsy of the eyelid is not reported with CPT code 11106 but is reported with CPT code 67810 (biopsy of the eyelid).
*This response is based on the best information available as of 3/28/24.
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 3/28/24.
Piriformis Muscle Injection
We perform Piriformis muscle injections in the office under ultrasound guidance, what code should we be reporting for this service?
Question:
We perform Piriformis muscle injections in the office under ultrasound guidance, what code should we be reporting for this service?
Answer:
The correct code(s) that should be reported for the service are 20552 for the piriformis muscle injection and 76942 for the ultrasound guidance.
Rationale: Per CPT Assistant April 2012
There is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection. Piriformis muscle injection(s) should be reported using CPT code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).
*This response is based on the best information available as of 3/28/24.
Submucosal Repair with Lateral Wall Implants
What code do I use for a unilateral repair of a nasal valve collapse with submucosal wall implants on one side?
Question:
What code do I use for a unilateral repair of a nasal valve collapse with submucosal wall implants on one side?
Answer:
You would report CPT code 30468 (Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)). You will need to append Modifier 52 (reduced services) to 30468 since the procedure was performed unilaterally, and CPT code 30468 is a bilateral procedure.
*This response is based on the best information available as of 3/28/24.
