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!
Stereotactic Navigation and Microscope
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?
Question:
Our provider performed a craniotomy for 2 separate lesions, one parietal and one occipital, through two separate craniotomy exposures. Stereotactic navigation and the operating microscope were needed for both resections. We are coding for the separate lesions as 61510, 61510-59, but can we also bill 61781 and 69990 twice with modifier 59 since they were needed for each separate lesion?
Answer:
No, stereotactic navigation and the microscope can each only be billed once per operative session.
*This response is based on the best information available as of 2/13/25.
Non-healing Wound ICD-10
I’m a newbie plastics coder and still learning. Are muscle flaps coded to the recipient site or by the donor site?
Question:
Should ICD-10 T81.31X– be reported for non-healing healing wounds?
Answer:
Thank you for your great question!
It would not be appropriate to report a non-healing wound with ICD-10 T81.31X, as this code is for the disruption of a closed wound.
There is no straightforward way to look up the ICD-10 code for a non-healing wound, either! That is because there is no specific code.
In this instance, ICD-10 T81.89X– would be assigned for the non-healing wound.
*This response is based on the best information available as of 2/13/25.
Pericapsular Nerve Group (PENG) block
Prior to 2025 we had been instructed to code a Pericapsular Nerve Group (PENG) block to 64999? What is the best CPT code for a PENG block in 2025?
Question:
Prior to 2025 we had been instructed to code a Pericapsular Nerve Group (PENG) block to 64999? What is the best CPT code for a PENG block in 2025?
Answer:
In this procedure, a local anesthetic is injected into the fascial plane located between the psoas tendon and the ilium. This targeted block affects the articular branches of the femoral, obturator, and accessory obturator nerves, which provide sensory innervation to the anterior capsule of the hip.
With the creation of the 2025 CPT codes:
64466 – Thoracic fascial plane block, unilateral; by injection(s), including imaging guidance, when performed
64467 – Thoracic fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed
64468 – Thoracic fascial plane block, bilateral; by injection(s), including imaging guidance, when performed
64469 – Thoracic fascial plane block, bilateral; by continuous infusion(s), including imaging guidance, when performed
64473 – Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed
64474 – Lower extremity fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed
CPT Codes 64473 and 64474 now represent the Pericapsular Nerve Group (PENG) block. The code selection is based on whether an injection or continuous infusion is performed.
*This response is based on the best information available as of 2/13/25.
Skin Cancer Screening
I see a number of patients with chronic problems such as dermatitis, psoriasis, history of skin cancer and acne to name a few. What defines stable versus exacerbation or progression?
Question:
What is the correct ICD-10-CM code for a skin screening exam for a patient who has a history of malignant melanoma?
Answer:
You should report 2 diagnosis codes; ICD-10-CM Z12.83 for the encounter for malignant neoplasm of skin and Z25.820 (personal history of malignant melanoma of skin).
*This response is based on the best information available as of 2/13/25.
Stent and Atherectomy in the Femoral and Popliteal Arteries
If a stent is placed in the common femoral artery and an atherectomy is performed in the popliteal artery, can both codes be billed?
Question:
If a stent is placed in the common femoral artery and an atherectomy is performed in the popliteal artery, can both codes be billed?
Answer:
The femoral/popliteal is one territory, so angioplasty, atherectomy and stent are reported with one code regardless of the number of interventions performed. CPT code 37227 represents stent and atherectomy within the same vessel and also includes angioplasty when performed.
*This response is based on the best information available as of 2/13/25.
Tongue Lesion
My physician coded a glossectomy but the documentation in the operative report indicated that a tongue lesion was removed. He wants to code 41120 for the glossectomy. I don’t think this meets the definition of a Glossectomy since there was no mention in the operative report that a portion of the tongue was removed.
Question:
My physician coded a glossectomy but the documentation in the operative report indicated that a tongue lesion was removed. He wants to code 41120 for the glossectomy. I don’t think this meets the definition of a Glossectomy since there was no mention in the operative report that a portion of the tongue was removed.
Answer:
Glossectomy codes require removal of a portion of the tongue, not just the lesion. If your physician is removing a lesion on the tongue, you should report CPT code(s) 41110-41114. When reporting a glossectomy, documentation must include what portion and how much of the tongue was removed. Also be sure to document tongue tissue removal and not just the lesion removal.
*This response is based on the best information available as of 2/13/25.
