Modifier for Bilateral Catheterization

Question:

Do you code bilateral catheterization codes with modifier 50? 

Answer:

Catheterization codes below the diaphragm can be coded with bilateral modifier 50, however, catheterization codes above the diaphragm should be coded with modifier 59 on the second code. (ex. Lower extremity 36245-50, upper extremity 36215, 36215-59). 

*This response is based on the best information available as of 1/30/25.

Global period for hernia repair

Question:

Do all hernia repairs have a 90-day global period? 

Answer:

No; inguinal, femoral and lumbar hernias have a 90-day global period. However, abdominal and parastomal hernia repairs have no global period, so E/M and other procedures may be separately reported with appropriate documentation the day following the procedure.

*This response is based on the best information available as of 1/30/25.

Is Scar Revision Still Complex Closure?

Question:

I have a scar revision for the abdomen and was going to assign CPT 13101. My coding teammate told me this is no longer the current coding recommendation. Is scar revision still reported with complex closure?

Answer:

Thank you for your inquiry!

Yes, your fellow coder is correct. At one point, CPT did include scar revision within the complex closure guidelines. However, in 2020, the guidelines associated with closures were changed, and scar revision was removed from the complex closure definition.

To address this change, a coding tip was placed within the CPT book in 2020 stating: “To report scar revision, see the Skin, Subcutaneous, and Accessory Structures, Excision-Benign Lesion subsection codes (11400-11471).”

According to CPT guidelines, scar revision is no longer reported with complex wound closure. Coding recommendations and guidelines are subject to change, so coders must review them and utilize up-to-date coding resources.

*This response is based on the best information available as of 1/30/25.

Secondary CSF leak following skull base surgery

Question:

Patient had to be taken back to the OR a day after an open skull base procedure due to a cerebrospinal fluid leak, and the dura was repaired with a synthetic graft material.  What is the correct CPT code for the repair, if it is separately reported, and do we need a modifier?

Answer:

Secondary repair of a CSF leak with a synthetic graft, after an open skull base procedure is reported with CPT code 61618 and modifier 78 would be appended for a related (complication) during the global period.

*This response is based on the best information available as of 1/30/25.

Discrepancy between Procedure Title and Documentation Details

Question:

If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?

Answer:

CPT codes are always chosen based on the documentation within the detailed portion of an operative record.  If the details within the body of the report do not match the “procedure title” listed in the beginning of the operative report, the provider should be queried for clarification and a possible addendum to the record if necessary.

*This response is based on the best information available as of 1/16/25.

Co-Planing of AC Joint

Question:

Our surgeon documented co-planing of the AC joint/distal clavicle. The diagnosis is bone spurs. Does this work support CPT code 29824, arthroscopic distal claviculectomy?  

Answer:

Thank you for your inquiry. Co-planing of the AC joint/distal clavicle does not support a distal clavicle resection. To report CPT code 29824, the documentation should include that the surgeon performed a “resection of the distal clavicle.” If the surgeon documents the amount, it should be based on the surgeon’s assessment of the amount of bone excised. 

In the early 2000’s the AAOS clarified the amount in the Global Service Data Guide that the amount of distal clavicle resection did have to be 1.0 cm. The AMA published a correction recently saying that the CPT code does not include the requirement of a specific bone-excision measurement of 1.0. This is consistent with the AAOS’s early position that the amount excised must be specific to the patient anatomy, physical size, and other factors. However, co-planing, removal of osteophytes, removal of bone spurs does not support a distal clavicle resection.  

*This response is based on the best information available as of 1/16/25.