Two Surgeons, Same Practice, Co-Surgery?

Question:

I have a case where two surgeons from the same practice are reconstructing the abdominal wall following tumor resection. They each perform their own side of the component separation, surgeon A on the right and surgeon B on the left. Each surgeon dictated their own op-notes for the side they performed, and now they want to bill as co-surgeons. I’m unsure if this is appropriate, so I seek KZA’s advice.

Answer:
Great question! While your surgeons each dictated their operative notes, this alone does not support co-surgery, modifier 62. Co-surgery from a surgeon's perspective is different from a coding perspective.

From a coding perspective, co-surgery involves two surgeons, typically of different specialties, with different skill sets, each performing separate portions (s) or parts of a procedure as defined by a CPT code.  Each surgeon would dictate their own operative note detailing their portions of the procedure performed. Again, this typically involves surgeons from different specialties, not two surgeons of the same specialty.

In the scenario above, two plastic surgeons perform one side of this bilateral component separation.

They should each be reporting their own CPT code,15734.

• Surgeon A: 15734

• Surgeon B: 15734 -XP

*Modifiers as directed by your payor. CPT code 15734 does not allow for RT/LT.  

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

Evacuation of recurrent subdural hematoma and drain placement

Question:

A patient returns two weeks after evacuation of a chronic subdural hematoma with a recurrence requiring another evacuation of the hematoma and placement of a subdural drain. What are the correct codes to report for the evacuation of the hematoma and placement of the drain?

Answer:

CPT code 61312 for re-do craniotomy for hematoma with modifier 58 appended for a more extensive procedure treating the same problem during the global period.  The drain would not be separately reported.

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

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.