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Two Aneurysm in the Same Artery
Craniotomy was performed for a patient who had two small aneurysms located in different sections of the middle cerebral artery. Can I code these as 61700, 61700-59?
Question:
A craniotomy was performed for a patient who had two small aneurysms located in different sections of the middle cerebral artery. Can I code these as 61700, 61700-59?
Answer:
No, clipping more than one aneurysms, via the same bone flap can only be reported once.
*This response is based on the best information available as of 11/14/24.
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 10/3/24.
Component Seperation
Our provider has documented abdominal closure by component separation, is there a separate CPT code for this closure or is it included in the main procedure?
Question:
Our provider has documented abdominal closure by component separation, is there a separate CPT code for this closure or is it included in the main procedure?
Answer:
Component separation, sometimes referred to as a rectus advancement flap, refers to a myocutaneous flap of the trunk (a flap of subcutaneous tissue, fascia and muscle with an intact vascular supply) represented by CPT code 15734. To report this code the providers documentation must demonstrate that the oblique, transversalis or transverse abdominus and rectus abdominus muscles have been incised and mobilized toward the midline with an intact vascular supply. This code can be reported only once for each side and bilateral modifier does not apply, so when performed bilaterally report as 15734, 15734-59.
*This response is based on the best information available as of 10/3/24.
Ultrasound Guidance for Vascular Access
What are the requirements to code 76937 for ultrasound guidance for vascular access?
Question:
What are the requirements to code 76937 for ultrasound guidance for vascular access?
Answer:
CPT code 76937 requires documentation of the following: ultrasound evaluation of potential access sites, localization and documentation of vessel patency, and the permanent recording and report must be noted and stored.
*This response is based on the best information available as of 10/03/24.
Paraspinal Intramuscular Injections
The type of injections our physicians perform are best described as paraspinal intramuscular injections or paraspinal nerve blocks without radiographic guidance. We are unsure how to code this procedure. What is the best code to use?
Question:
The type of injections our physicians perform are best described as paraspinal intramuscular injections or paraspinal nerve blocks without radiographic guidance. We are unsure how to code this procedure. What is the best code to use?
Answer:
Any injection around the spine without imaging guidance is best described as a trigger point injection. The number of muscles injected determines whether CPT code 20552 (1 or 2 muscles) or CPT code 20553 (3 or more muscles) is billed. If one muscle is injected multiple times, it should be coded with the lower code 20552.
*This response is based on the best information available as of 9/16/24.
Fall Risk Prevention Program: Part 2
We read and received your recent Coding Coach on the Fall Risk Prevention Program and directive to report Category II CPT codes for this service. We have a follow-up question. Why would we not be able to report CPT code 97750 for this service, and can this code be billed incident- to the physician if the MA performs the work?
Question:
We read and received your recent Coding Coach on the Fall Risk Prevention Program and directive to report Category II CPT codes for this service. We have a follow-up question. Why would we not be able to report CPT code 97750 for this service, and can this code be billed incident- to the physician if the MA performs the work?
Answer:
Per CPT coding guidelines, many parameters are associated with reporting CPT code 97750. CPT code 97750 is not used for a MIPS tracking code. Reporting this code requires that the work be performed by an MD, DO, or PT. An MA may not perform the work associated with this code and bill incident - to, as an MA is not a Qualified Healthcare Professional (QHP).
*This response is based on the best information available as of 9/16/24.
