Mohs Surgery Documentation

Question:

What should be documented to support medical necessity for Mohs surgery? 

Answer:

The patient should have a confirmed pathology report.  Specific criteria must be documented: type of cancer, location, size, and other factors (healthy, immunocompromised, aggressive, etc.) for coverage.  The medical records should clearly show that Mohs surgery was chosen because of the lesion's complexity, size and location and why other approaches are not medically necessary and reasonable. The operative notes and pathology documentation in the patient's medical record must clearly show that Mohs micrographic surgery was performed using the accepted Mohs technique, with the same physician performing both the surgical and pathology services. The notes should also contain the location, number, and size of the lesion(s), the number of stages performed, and the number of specimens per stage. The Mohs surgeon must describe the histology of the specimens taken in the first stage. That description should include depth of invasion, pathological pattern, cell morphology, and, if present, perineural invasion or the presence of scar tissue. For subsequent stages, you may note that the pattern and morphology of the tumor (if still seen) are as described for the first stage; if differences are found, note the changes.  Some payors have additional requirements to support the medical necessity of Mohs.  It is important to check payor policies to ensure compliance with the payor.

*This response is based on the best information available as of 5/23/24.

Suctioning Debris from the Ear Canal

Question:

I just suctioned debris from the ear canal as there was no impacted cerumen.  Can I still use 69210? 

Answer:

No.  CPT 69210 is specifically for removing impacted cerumen.  There is no CPT code for suctioning an ear canal of debris (e.g., Swimmer’s ear, otitis externa).  You would report an E/M code and you could also report 92504 if you used the microscope to suction the ear canal.  

*This response is based on the best information available as of 5/23/24.

Intradiscal Steroid Injection

Question:

Is there a CPT code for an intradiscal steroid injection for “discogenic pain?”   

Answer:

There is no CPT code for an intradiscal steroid injection. You will report an unlisted code, 22899 or 64999. Most payors consider non-thermal glucocorticoid injections as not medically necessary. Follow your payor policies for reporting unlisted procedures and procedures that may be denied as not medically necessary.  

*This response is based on the best information available as of 5/23/24.

Moderate Sedation Documentation

Question:

Is use of the nurse flow sheet when billing for moderate sedation with our pain injection procedures allowed?

Answer:

Per CPT coding guidelines, when billing for moderate sedation an independent trained observer is required.  An independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties (e.g. assisting at surgery) during the procedure. 

Moderate sedation must be documented in the body of the procedure report; a separate flow sheet is not sufficient for the surgeon documentation.  Document “ I personally supervised Mary Brown RN providing 45 minutes of moderate sedation with XX mg Versed and XX mg Fentanyl”. 

*This response is based on the best information available as of 5/23/24.

Painful Spinal Hardware

Question:

Our physician injected 0.5% Marcaine and 80 mg of Depo-Medrol to existing spinal hardware (eg, pedicle screws) at L4, L5, and S1 bilaterally for a patient complaining of painful hardware. Can CPT code 64483 be reported? 

Answer:

No. CPT code 64483, (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), represents transforaminal epidural nerve root injection performed in the lumbar region. There is no specific CPT code for the injection of spinal hardware. CPT code 64999, Unlisted procedure, nervous system, would be most appropriate to describe the injections for pain performed outside the foramen, as indicated in the clinical scenario provided in this inquiry. Although three spinal level (L4, L5, S1 bilaterally) injections were performed, code 64999 should be reported only once to represent the multiple injections. 

*This response is based on the best information available as of 5/9/24.

Soft Tissue Tumors

Question:

I excised a 1 cm lipoma from the patient’s scalp and reported CPT code 21011. I also performed an intermediate repair of 1.4cm and reported CPT 12031. I submitted the claim to the insurance company, and they denied the repair. Why can’t I get paid for the repair? Is the CPT code I submitted incorrect?

Answer:

When a soft tissue tumor excision is performed, the direct closure (simple or intermediate repair) is included in the soft tissue tumor excision and cannot be reported separately. According to CPT Assistant February 2010; a complex repair may be reported when extensive undermining or other techniques are used to close the defect and the elevation of tissue planes to permit resection of the tumor is included in the soft tissue tumor excision. Adjacent tissue transfer, split-thickness/full-thickness graft, muscle flap, etc. may also be reported separately. Keep in mind, though, that some payors may include the complex repair as payment for the soft tissue tumor excision.

Source: CPT Assistant February 2010

*This response is based on the best information available as of 5/9/24.