Subcutaneous vs Subfascial

Question:

If the provider says in their documentation that they went into the subcutaneous tissue and to the fascia to excise a 4 cm lipoma from the back, is this subfascial? This always trips me up when coding!  

Answer:
In the scenario above, this is only to the fascia, not through or below the fascia. The lipoma excision is only within the subcutaneous tissue.

Based on the scenario presented, the appropriate CPT code is 21931.  

*This response is based on the best information available as of 12/5/24.

“Incident-to” vs “Direct” Billing

Question:

Our nurse practitioner saw a new patient (Medicare) in the office to evaluate sinus complaints. The nurse practitioner developed the plan of care. The patient was scheduled to follow up with the Nurse Practitioner. The patient returned to the nurse practitioner for a return visit with the same problem, and there were no changes in the plan of care. Can the NP bill this “Incident to” the physician since it is an established patient with an established plan of care and the physician was in the office?

Answer:

This is a great question. While the second visit is for an established patient with no change in the care plan, the nurse practitioner must still bill it as “direct.” To move this to an “Incident-to” encounter, there must be an independent encounter with the physician develops the plan of care.

*This response is based on the best information available as of 12/5/24.

Appealing Intraoperative EEG/EMG Denials

Question:

I am new to coding for neurosurgery, and we are receiving denials for intraoperative EEG and EMGs; what documentation should we use for appeal?

Answer:

Intraoperative monitoring such as EEG, EMG and SSEP are inclusive to the procedure performed and not separately reported by the operating surgeon or the assistant. (Exception: 95961-26 may be reported when the surgeon performs cortical/subcortical mapping, such as in an awake craniotomy. For denials in these instances, medical necessity and detailed documentation to support the mapping should be sent on appeal)

*This response is based on the best information available as of 12/5/24.

Risk of Patient Management

Question:

Is a decision to NOT perform an injection with risk factors discussed “moderate” risk?

Ex: The patient has done 6 weeks of physical therapy for their spinal stenosis, which has provided some relief, but he is not at the treatment goal. We discussed performing a lumbar epidural steroid injection with the risks of the procedure, including bleeding, infection, and nerve damage. The patient is a diabetic, and we discussed the risks of the corticosteroid injection elevating blood glucose levels. After this discussion, he elected to continue PT and avoid injection at this time.

Answer:

Yes, a decision for treatment, in this case, an epidural injection, is a medical decision made by the physician. Even if the patient defers this recommendation, it still constitutes a medical decision and one with documented patient and procedure risks.

Per CPT Guidelines:

For the purposes of MDM, the level of risk is based upon the consequences of the problem (s) addressed at the encounter when appropriately treated. Risk also includes MDM for initiating further testing, treatment, and/or hospitalization.

1) The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified healthcare professional during the reported encounter.

2) Includes the possible management options selected and those considered but not selected after sharing MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care.

*This response is based on the best information available as of 12/5/24.

Is Documentation of HPI and Exam Necessary in Determining a level of E/M?

Question:

With the 2021 and 2023 Guideline changes, is it necessary to document an HPI and Exam when neither counts towards the level of service?

Answer:

As described in the most recent AMA E/M guidelines, documentation of a history of present illness (HPI) and an exam are no longer required to contribute to the level of an E/M service. Today, documentation of medical decision-making or time is the sole determinant supporting a level of E/M.  E/M documentation should include a medically appropriate history and examination. While the nature and extent of the history and exam are determined by the clinician, they add to the medical necessity of the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical providers.

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

ENT Modifier 25

Question:

Does the following scenario meet the modifier 25, “significant, separate service” rules? 

The patient presents with watery eyes, sinus, nasal congestion, and drainage.   The physician evaluates the patient and does a nasal endoscopy to evaluate the upper airway further.   The physician diagnoses the patient as having acute sinusitis and writes a prescription for an antibiotic.  Instructions are given on taking the medications and following up if the patient has seen no improvement after 72 hours.   

May we report an E&M-25 and the nasal endoscopy?

Answer:

Yes, the scenario you present meets the definition of modifier 25. The E&M was not performed for the purpose of the nasal endoscopy, and the physician had additional decision-making related to the management of the sinusitis.

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