Orthotic Management Codes with Fitting and Adjustment HCPCS code

Question:

We recently hired a physical therapist to allow patients to receive therapy in our office if they wish. We have never coded for therapy services prior to his arriving and are unsure if his recommended CPT codes are correct.  

The therapy service will be provided on the same day as the physician’s E&M service.  

The physician wrote an order for physical therapy and a knee orthotic with locking knee joints, prefabricated, and will bill HCPCS Code L1831 with an E&M code in addition to physical therapy.  

The therapist suggested CPT codes are: 

97162 (Initial physical therapy evaluation, moderate complexity) 

97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minute) 

We are not questioning the accuracy of CPT code 97162 but seeking guidance on CPT code 97760. 

Answer:

Thank you for your inquiry to KZA. You are correct to question the accuracy of reporting the orthotic management codes with this specific DME L code. 

HCPCS code L1831 is defined as “Knee orthosis (KO), locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment” The inclusion of “fitting and adjustment” in the code descriptor precludes reporting 97760 as this would define overlap between the valuation of the L code and CPT code 97760; both include fitting in their definitions.  

Remember to append modifier 25 on the therapist evaluation CPT code to show the significant separate service rules were met (differentiation between physician E&M service and therapist evaluation code).  

*This response is based on the best information available as of 4/25/24.

Destructions

Question:

What CPT code should I bill for the destruction of seborrheic keratosis? My physician told me to bill 17000 and 17003 for additional destructions.

Answer:

CPT codes 17000 and 17003 are used to report actinic keratosis (AK) destruction, not seborrheic keratosis (SK) destruction(s).  The correct codes are 17110 for up to 14 lesions, and 15 or more lesions are reported with CPT code 17111. Make sure the documentation includes the type of lesion, the number of lesions destroyed and the site of each lesion.

*This response is based on the best information available as of 4/11/24.

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

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

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

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.