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Percutaneous Fracture Fixation
Our surgeon performed a closed reduction of a medial malleolar fracture with percutaneous fixation. There is no documentation of an open reduction, and we are unsure how to report this procedure.
Question:
Our surgeon performed a closed reduction of a medial malleolar fracture with percutaneous fixation. There is no documentation of an open reduction, and we are unsure how to report this procedure.
Answer:
Percutaneous fixation of a medial malleolar fracture is reported with an unlisted code, 27899. Work with your surgeon to identify a comparison code; one option is CPT code 27762 (Closed treatment of medial malleolus fracture with manipulation, with or without skin or skeletal traction).
*This response is based on the best information available as of 12/5/24.
Laparoscopic vs Percutaneous
What is the difference between laparoscopic and percutaneous procedures and how do we choose the correct CPT code for these?
Question:
What is the difference between laparoscopic and percutaneous procedures, and how do we choose the correct CPT code for these?
Answer:
Laparoscopy refers to a flexible tube (laparoscope) inserted via small incisions, typically in the abdominal or pelvic cavity for direct visualization of the body cavity and organs. These CPT codes will have the term “laparoscopic” in their description.
Percutaneous procedures are minimally invasive procedures performed via a puncture or minor small incision with no direct visualization of structures. They are performed with imaging guidance. These CPT codes will have the term “percutaneous” in their code description.
*This response is based on the best information available as of 12/5/24.
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.
