Platelet Rich Plasma (PRP) Injections

Question:

What codes should we be reporting when we do PRP injections in our office?

Answer:

Code 0232T, Injection (s), platelet rich plasma, any site, with image guidance, harvesting and preparation when performed, is used to report this procedure. A PRP injection is bundled into the tendon sheath, trigger point, and joint injection CPT codes, thus, these codes should not be coded in addition to 0232T. Code 0232T is only reported when it is the only procedure performed. As a Category III code, it is not valued by Medicare (has 0 RVUs assigned), so payment is problematic, and most Medicare carriers do not pay for PRP. Billing a PRP injection as a trigger point injection is a misrepresentation of the actual service provided.

*This response is based on the best information available as of 6/20/24.

Arthrodesis Codes for Reporting Both Thoracic and Lumbar

Question:

Our neurosurgeon performed arthrodesis on a patient from T11 – L3 and we coded as 22612, 22610 and 22614 x2 and 22610 is being denied; can we add modifier 59?

Answer:

No; CPT codes 22610 and 22612 are both primary codes, and should not be reported together, if performed at the same operative session.  Correct reporting of an arthodesis that crosses a spinal junction, is reported  with one primary code and all other interspaces reported with the additional interspace code +22614.   

Select a primary code where most of the work is performed, in this case, lumbar.  So report 22612 as the sole primary code and 22614 x 3 for the additional interspaces. 

*This response is based on the best information available as of 6/20/24.

Cancer Surveillance

Question:

When a patient comes in for head and neck cancer surveillance with severe xerostomia because of radiation therapy, and the physician does a complete workup for the xerostomia, and there is detailed documentation about the xerostomia, can we bill an E/M service along with the flexible laryngoscopy (31575)?

Answer:

If the patient is seen for follow-up for head and neck cancer and they are also being treated for xerostomia you would be able to report a separate E/M service as long as the workup for the xerostomia is documented and treated or there is a change in plan of care to support the evaluation and management service.

*This response is based on the best information available as of 6/20/24.

CPT and ICD-10-CM Codes in Operative Notes

Question:

What is KZA’s perspective when a surgeon documents the CPT codes within the clinical operative note? 

Answer:

KZA discourages using CPT and ICD 10 codes within the operative notes. While documenting details of each procedure is key within the operative report (both the header and within the body of the note), adding CPT and ICD 10 diagnosis codes creates an issue if the coding is incorrect. The operative report is part of the legal medical record, and payors may question the accuracy and validity of the entire report if the codes documented within the record are different than the codes billed. For this reason, we advise against documenting the specific CPT and ICD 10 codes within the operative report to prevent other denial and stall tactics. 

*This response is based on the best information available as of 6/20/24.

Assistants at Surgery

Question:

We have surgeons who use their “Fellows” per their program as “Assistants at Surgery” and want to bill the corresponding codes under the “Fellow” with the “80” modifier. Is this OK?  

Answer:

Under the current CMS guidelines, fellows are considered residents when practicing within their GME program, so their services as surgical assistants would not be billable. However, there are certain circumstances where a fellow may bill for their own services when practicing outside their GME program (e.g., in the Emergency Department, seeing patients as a primary physician (not in an orthopedic capacity). A Fellow in a private Fellowship and employed by the group practice is billable as a Fellow. These are non-GME-funded fellowships. 

 In an academic setting, we suggest that questions regarding fellow reporting be referred to Compliance for discussion and direction. CMS has very specific guidelines regarding moonlighting that can be found here: https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf 

*This response is based on the best information available as of 6/6/24.

Incision and Drainage (I&D)

Question:

My physician wants to know the difference between a simple and complicated I&D.  I cannot find any specific guidance.

Answer:

A simple or single I&D includes drainage of the pus or purulence from the cyst or abscess. The physician leaves the incision open to drain on its own, allowing for healing with normal wound care. A complex I&D includes placing a drainage tube to allow for continuous drainage or packing to facilitate healing. In certain cases, tissue excision, primary closure, and/or Z-plasty may be required. CPT code 10060 is a simple or single I&D and is typically reported when an abscess or cyst is opened with a surgical instrument, allowing the contents to drain. The lesion may be curetted and irrigated. CPT 10061 often involves larger abscesses requiring probing to break up loculations and packing to promote ongoing drainage. 

You should report CPT code 10060 for incision and drainage of a simple or single abscess and CPT 10061 for complex or multiple cysts. Complex or multiple cysts may require surgical closure at a later date. 

*This response is based on the best information available as of 6/6/24.