Evaluation and Management (E/M)

Question:

We had a new patient who came in for evaluation for itchy skin eruptions that had never been treated. He documented a complete history and full skin examination and diagnosed the patient with psoriasis, which was inadequately controlled, and performed an intralesional injection (11900) in the patient’s hand, which was the area of concern.  He found psoriasis on the scalp, hand, and chest and wrote the patient a prescription for Clobetasol ointment and spray.  My question is, can we bill an E/M service with Modifier 25 since he did a complete history and skin exam? 

Answer:

The E/M services require a clinically relevant history and examination. This will not determine whether Modifier 25 is supported. What does support a significant separate E/M service is that in addition to the intralesional injection, the physician developed a plan of care that not only included the injection but also prescribed medication to treat the areas. An E/M service based on medical decision-making or time 99203-99205 (new patient) can be reported with modifier 25 in addition to CPT code 11900.

*This response is based on the best information available as of 7/11/24.

Documentation for Modifier 22

Question:

What documentation is needed to report modifier 22?

Answer:

To be able to append modifier 22 which represents an increased procedural service, the provider needs to demonstrate that the work required was substantially greater than normally expected. To support this, the documentation must provide more than a blanket statement and include details as to why the work was greater. For example: “extensive lysis of adhesions took greater than 90 mins prior to reaching (the intended site)”.  The “what made it more work” is less crucial than the “details that explain why” it was more difficult so that payors will allow increased reimbursement. 

*This response is based on the best information available as of 7/11/24.

Microtia Surgery

Question:

What CPT code is appropriate for creating a cutaneous pocket fashioned for the framework for stage 1 of a microtia surgery? 

Answer:

The appropriate code for creating a cutaneous pocket in the context of stage 1 microtia surgery is CPT 14061 (adjacent tissue transfer).  This code corresponds to the procedure involving creating a cutaneous pocket in the right ear and transferring. The cutaneous pocket is essential for accommodating the framework created during reconstruction.  Since the code is selected based on anatomic location and sq centimeter size be sure to document this information in the operative report. 

*This response is based on the best information available as of 7/11/24.

Coding For Arthroscopic Subacromial Decompression

Question:

We received a denial from one of our payors saying the documentation did not support CPT code 29286. The surgeon documented bursectomy, release of ligament and removal of anterior osteophytes. Does this support CPT code 29826? 

Answer:

Thank you for your inquiry. Unfortunately, the payor is correct. The removal of osteophytes with or without the bursectomy and ligament release does not support CPT code 29826. To report the subacromial decompression, documentation must support an acromioplasty, which is a reshaping of the acromion. Typically, surgeons will document the work and state they took the acromion from a Type III to a Type I.  

*This response is based on the best information available as of 7/11/24.

Removal of Ventricular Catheter

Question:

What code would be used for removal of a ventricular catheter?

Answer:

There is no code for ventricular catheter removal, it is included in the placement as it is expected to be removed.

*This response is based on the best information available as of 7/11/24.

Transcutaneous Magnetic Nerve Stimulation

Question:

How is this service reported, we are having trouble locating a CPT code, should we use an unlisted code?

Answer:

This service should not be reported with an unlisted code.New Category III codes were created in 2023 to report transcutaneous magnetic nerve stimulation of peripheral nerve by focused low frequency electromagnetic pulse with noninvasive electroneurographic localization. This new technology is used in the management of chronic pain following a traumatic injury. The treatment is repeated over several months. Injured nerve is localized using magnetic stimulation at the time of the initial treatment. The skin is marked with photographic record to facilitate rapid localization of the correct site for subsequent treatments and the appropriate amplitude of magnetic stimulation.  

Nerve conduction may be used as guidance to confirm precise localization of the injured nerve but is not separately reported as a diagnostic study. If a separate diagnostic nerve conduction study is performed prior to the decision to treat with transcutaneous magnetic stimulation, then it may be reported separately.  

• 0766T Transcutaneous magnetic stimulation by focused low frequency electromagnetic pulse, peripheral nerve, initial treatment, with identification and marking of the treatment location, including noninvasive electroneurographic location (nerve conduction location) when performed; first nerve  

• +0767T Each additional nerve (List separately in addition to code for primary procedure 

*This response is based on the best information available as of 7/11/24.