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Neck Dissection
My physician did a total thyroidectomy with a modified radical neck dissection. Can I report the radical neck dissection with the thyroidectomy?
Question:
My physician did a total thyroidectomy with a modified radical neck dissection. Can I report the radical neck dissection with the thyroidectomy?
Answer:
If your physician performed the total thyroidectomy using CPT code 60240 and modified radical neck dissection (38724), both procedures may be reported during the same operative session. The first listed code on the claim should be CPT 38724. Modifier 59 should be appended to CPT code 60240 (lower RVU) since it is bundled under the National Correct Coding Initiative.
*This response is based on the best information available as of 9/5/24.
Moderate Sedation
Can our vascular surgeon bill for moderate sedation if an RN was present to observe and monitor the patient?
Question:
Can our vascular surgeon bill for moderate sedation if an RN was present to observe and monitor the patient?
Answer:
Yes; an RN has the knowledge and experience to observe and monitor the patients vital signs, including BP, oxygen levels, heart rate and level of consciousness under the direct supervision of the physician.
*This response is based on the best information available as of 7/11/24.
Evaluation and Management (E/M)
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?
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
What documentation is needed to report 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
What CPT code is appropriate for creating a cutaneous pocket fashioned for the framework for stage 1 of a 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
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?
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.
