Choose your specialty from the list below to see how our experts have tackled a wide range of client questions.
Looking for something specific? Utilize our search feature by typing in a key word!
Billing an E/M Service after Mohs when a repair is indicated
Our Mohs surgeons sometimes perform an adjacent tissue transfer or a flap after Mohs surgery. Since they decided to do the flap after Mohs, they want to bill an E/M service with Modifier 57. I don’t think this is correct. Can you help clarify?
Question:
Our Mohs surgeons sometimes perform an adjacent tissue transfer or a flap after Mohs surgery. Since they decided to do the flap after Mohs, they want to bill an E/M service with Modifier 57. I don’t think this is correct. Can you help clarify?
Answer:
The E/M service should not be reported after Mohs surgery when a decision is made for a repair, flap, or graft. Even though a flap has a 90-day global period, the surgical decision was made to perform Mohs, the primary procedure. The intent of the E/M with Modifier 57 for a procedure with a 90 global period is when the initial decision is made to perform the primary procedure. The repair is secondary; therefore, billing an E/M service is inappropriate. The discussion and recommendation for the repair is part of the pre-service work for the repair and the E/M service is inherent to the procedure.
CMS Global Surgery Workbook says: “When the decision to perform the minor procedure comes immediately before a major procedure or service, we consider it a routine pre-operative service and you can’t bill a visit or consultation with the procedure. MACs may not pay for an E/M service billed with CPT modifier –57 if it’s provided on the day of, or the day before, a procedure with a 000- or 010-day global surgical period. “
Source: https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
*This response is based on the best information available as of 12/5/24.
Intravascular Ultrasound (IVUS)
How do we code for intravascular ultrasound of lower extremity vessels? Can it be billed along with the placement of a lower extremity stent?
Question:
How do we code for intravascular ultrasound of lower extremity vessels? Can it be billed along with the placement of a lower extremity stent?
Answer:
Intravascular Ultrasound (IVUS), CPT code +37252 (noncoronary) and +37253 (noncoronary) for each additional vessel, can be coded when vessels are examined during a diagnostic procedure or before, during, or after a therapeutic intervention (e.g., stent or stent graft, angioplasty, atherectomy, embolization, thrombolysis, transcatheter biopsy). However, if a lesion extends across the margins of one vessel into another, only one code should be reported. These add-on codes must be reported with the appropriate base code. IVUS is included in the work of CPT codes 37191, 37192, 37193, and 37197 for intravascular vena cava filter (IVC) and should not be reported separately with those procedures.
*This response is based on the best information available as of 12/5/24.
Subcutaneous vs Subfascial
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!
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
Our Nurse Practitioner saw a new patient (Medicare) in the office for evaluation of sinus complaints. He 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 no changes in the plan of care. Can he 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?
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
I am new to coding for neurosurgery, and we are receiving denials for intraoperative EEG and EMGs; what documentation should we use for appeal?
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
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.
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.
