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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 4/11/24.
Genicular Nerve Injection
What is the correct code to report when our physician performs a ganglion impar injection with Depo-Medrol and Lidocaine?
Question:
What is the correct code (s) to report when the physician injects the superomedial and superolateral branches of the genicular nerve for knee pain with a steroid?
Answer:
The correct code to report for this service is 64454 (Injection (s), anesthetic agent (s) and/or steroid; genicular nerve branches including imaging guidance, when performed) with modifier 52 (Reduced Services). If all 3 nerve branches of the genicular nerve (superolateral, superomedial, and inferomedial) are not injected the service is reported with modifier 52. CPT code 64454 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 4/11/24.
Stent vs. Embolization or Both
If the surgeon uses a covered stent and performs an embolization on a patient with a pseudoaneurysm, can we bill for both the stent and removal of the embolus?
Question:
If the surgeon uses a covered stent and performs an embolization on a patient with a pseudoaneurysm, can we bill for both the stent and removal of the embolus?
Answer:
If a covered stent is deployed as the sole management of an aneurysm, pseudoaneurysm or vascular extravasation, then the stent deployment should be reported and not the embolization code.
*This response is based on the best information available as of 4/11/24.
Post Operative Infection
What CPT code would I use for an I&D of a complicated postoperative wound infection?
Question:
What CPT code would I use for an I&D of a complicated postoperative wound infection?
Answer:
The correct CPT code is 10180 (Incision and drainage, complex postoperative wound infection).
*This response is based on the best information available as of 4/11/24.
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.
