Documentation for Endovascular Procedures

Question:

What information needs to be documented in the body of the operative report for endovascular procedures?

Answer:

Documentation must include a thorough description of the procedure detailing vascular access points, catheterizations including the end point of all catheterizations, description of all interventions performed including placement of any prosthesis, results of the intervention, percentage of residual stenosis for all vessels treated, and any attempted procedures that were not successful or not able to be completed. Radiological supervision for diagnostic angiograms with rationale, vessels visualized, and findings should also be detailed in a separate paragraph.

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

Adjacent Tissue Transfer

Question:

We are having some controversy in the office.  Many of our physicians state the sq cm size of the primary and secondary defect combined is enough to support an Adjacent Tissue Transfer.  Can you help?

Answer:

To properly code for an Adjacent Tissue Transfer (ATT), you must document the site of the ATT, the size of the primary defect, the size of the secondary defect, and the total square centimeter size (add the size of the primary defect, the secondary defect and report the total size

*This response is based on the best information available as of 10/3/24.

Conversion of UKA to TKR

Question:

I took a significant leave from coding orthopedics; now, I'm back in the trenches coding for ortho. Has the coding recommendation for revising a unicompartmental knee arthroplasty to a total knee replacement changed? I'm confused; our surgeons gave me an AAOS Now Article from 2023, and I have the CPT Assistant article from 2013. Can you please advise?  

Answer:

In the hip section of CPT, we have code 27132 (Conversion of a previously open procedure to total hip arthroplasty). Unfortunately, no code exists in the knee section of the CPT book. 

In June 2023, an AAOS Now article was published that addressed this question with two different coding directions. 

· The first coding option outlined, if the conversion is simple with primary implants, is to report CPT 27447 and append modifier 22 for the increased work due to the altered field. 

· The second coding option outlined states is to report code 27487 if bony defects require augments or stems. 

KZA understands that the June 2023 article was superseded by a revised article removing the published recommendation. The revised article can be found on the AAOS website in the Archives section for June 2023. 

However, a CPT Assistant addressed this question in July 2013, stating to report this coding scenario with CPT 27487 and append modifier 52 (reduced services). 

KZA understands why you are confused! As you see, there are now two different sources with three different coding recommendations, which leaves a coder to wonder which coding guidance to follow when having to code a conversion of a UKA to a TKR. It's not a great spot for a coder to be in when you have a case to code! While the CPT Assistant from July 2013 is older, KZA recommends following the AMA CPT article until the AMA publishes an updated article. A conversion of UKA to a TKR/TKA is 27487-52. 

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

Number and Complexity of Problems Addressed

Question:

I see a lot of patients with chronic pain and other issues. What defines “stable” vs. “exacerbation or progression”?

Answer:

Number and Complexity of Problems Addressed

Per the CPT guidelines, ‘stable’ for the purposes of categorizing medical decision-making is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

A chronic illness with exacerbation, progression, or side effects of treatment is a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control the progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.

For all E/M codes, while it doesn’t contribute to code selection, documenting the history of the present illness (HPI) is crucial documentation. The provider must document each problem addressed and indicate stable, acute, chronic, exacerbation, etc., for each problem. Incorporate the terms exacerbation (getting worse) and severe exacerbation (getting significantly worse, requiring significant treatment changes) in your assessment when applicable. Be sure to document a recommendation (plan of care) for each problem addressed (i.e., stable, make changes, order additional testing).

*This response is based on the best information available as of 11/17/24.

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.