Soft Tissue Tumors

Question:

I just started coding for Dermatology practice. I need some clarity on soft tissue tumor excisions. My physicians are telling me that when a soft tissue tumor excision is performed, the procedure includes all repairs, including a flap repair. If the physician removes a soft tissue tumor and does a flap on the same day, can I report the flap separately?

Answer:

All soft tissue tumor CPT codes 21011-21016 for the head, face, or scalp and 21552-21558 (neck and thorax) are reported based on anatomic location and centimeter size. These codes include direct closure (e.g., simple, intermediate, and complex repair). However, other types of closure may be separately reported, such as adjacent tissue transfer, split-thickness/full-thickness graft, muscle flap, etc., in addition to the soft tissue tumor excision.

*This response is based on the best information available as of 11/14/24.

Risk of Patient Management

Question:

I am a Pain Management Physician. I have a patient with lumbar spinal stenosis who has completed two months of physical therapy and 2 epidural steroid injections, but significant pain still persists. Since extensive conservative management has failed to provide adequate relief, I now recommend a surgical consultation with a spine physician. I document, “We discussed risks of surgery including bleeding, infection, nerve damage as well as patient-specific risks including hypertension. After discussing the risks and benefits of surgery, the patient elects to continue conservative management”. Does this count as a decision for surgery (moderate risk)? I am not clear on if I can make a “decision for surgery” as a non-surgical physician.

Answer:

Thank you for your inquiry. In answer to your question, no, this would not be a decision for surgery on the MDM table of risk. You are not the surgeon; you are considering a surgical consultation. The surgeon is the provider who makes the decision for surgery.

*This response is based on the best information available as of 10/17/24.

ENT Modifier 24

Question:

Q: My physician saw a patient three weeks post-op after an adenoidectomy. The patient is complaining of ear pain at this visit. Can I report am E/M service with Modifier 24?

Answer:

According to CPT and Medicare payment rules, an unrelated problem evaluated and managed during the global period is reportable. The unrelated diagnosis is the “key” to reporting the E&M service during the global period. Modifier 24 must be linked to identify the E&M as unrelated to the surgical procedure during the global period.

Verify that there is not a payor-specific rule, for example, that assigns different global days, e.g., 30 days versus 10 days, to the procedure. Appeal all inappropriate denials. Track the pattern of denials by payor to determine if the trend is payor-specific.

*This response is based on the best information available as of 10/31/24.

Lower Extremity Intravascular Lithotripsy

Question:

How do we code for lower extremity Intravascular Lithotripsy (IVL)? Can physicians use HCPCS codes C9764-C9767?

Answer:

There is currently no CPT code to represent physician coding for Intravascular Lithotripsy of the lower extremities. Physicians should not report the facility codes C9764-C9767, instead report these procedures with unlisted vascular CPT code 37799 and compare to an angioplasty code for the same vessel.

*This response is based on the best information available as of 10/31/24.

Laminoplasty Scenarios

Question:

In our spine practice, we often see different laminoplasty scenarios for coding. Is it ever appropriate to report decompression in addition to laminoplasty (63051)? Hope you don’t mind, but I have included a couple of commonly seen laminoplasty scenarios from our practice that we are eager for KZA’s opinion. 

Scenario #1 Our surgeons wish to bill 63051 for laminoplasty (C4-C6) and 63020 & 63035 for foraminotomies (C4/5 & C5/6) because they say it's a significant amount of work. We struggle with this one, is this appropriate? 

Scenario #2 Laminoplasty performed from C4-C6, and decompression performed at C2/3?   

Scenario #3 Laminoplasty performed from C4-C6 with partial laminectomies performed at C3 & C7.  

Answer:

 Great questions and scenarios!  Most importantly, laminoplasty codes should not be reported with arthrodesis, instrumentation, decompression, or osteoplastic reconstruction at the same vertebral segment.  Meaning, if the laminoplasty is from C4-C6 and the foraminotomies are performed at C4/C5 & C5/C6, only CPT 63051 is reported.    

Scenario #1 CPT 63051 is only reportable.  

 * KZA is not addressing the accuracy of CPT code 63020/63035 for a foraminotomy in non-related cases. 

Scenario #2 CPT 63051 & 63045-59 (distinct separate procedure) or XS modifier, as directed by your payor to reflect decompression, was performed at a separate level from laminoplasty.    

Scenario #3 Only CPT 63051 is reportable, the partial laminectomies above and below the laminoplasty are considered included to complete the laminoplasty. 

*This response is based on the best information available as of 10/31/24.

Use of Robotic Systems During Surgical Procedures

Question:

What is the code for a robotic procedure?

Answer:

When surgical procedures involve the use of robotic surgical systems, the robotic component can be represented by HCPCS code S2900.  However, there is no RVU associated with this code, and it is not reimbursed under the Medicare payment system.   The best practice is to set a fee for the extra physician work involved with robotic assistance, document medical necessity for the use of the robot, and incorporate this code into billing for tracking purposes when used.

*This response is based on the best information available as of 10/31/24.