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The General Surgery Coding Coach 2006 Archives
| December 1, 2006 - Modifier 58 Staged or Related Procedure or Modifier 79 Unrelated Procedure |
| Question:Our physician performed a partial thyroidectomy, pathology returned positive and the physician took the patient back to the operating room for a completion thyroidectomy. Our surgeon was told to append a modifier 79 (unrelated surgical procedure) and I am saying modifier 58 (staged or related procedure) because the completion thyroid is more extensive surgery for the disease process. Which modifier is correct?
Answer:Modifier 58 is the correct modifier in this situation. The physician is still treating the thyroid disease and the subsequent procedure is more extensive as it requires complete removal of the thyroid to treat the disease process. While some may advise modifier 79 because the diagnosis changed from a benign pathology to a malignant pathology, he is still treating the same anatomic area.
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| November 15, 2006 |
| Question:Our physicians have a question about how to report an E&M service when the patient is unconscious and they cannot obtain a full history. Since consults and hospital admission codes require documentation of 3 out of 3 key components, how do we handle the history if the patient is unconscious?
Answer: Good question and hopefully this is a situation that is an infrequent occurrence.According to the AMA CPT Guidelines, the physician in this situation is given “credit” for a comprehensive history. The following is an excerpt from the AMA CPT Assistant regarding E&M documentation criteria. You will note in the statement, that this is a combined Medicare (now CMS, formerly HCFA) and AMA position.
On April 27, 1998, the American Medical Association convened the physician leaders and staffs of organized medicine for an open and candid exchange of opinions and concerns with representatives from the Health Care Financing Administration, Health and Human Services Office of the Inspector General, and the CPT Editorial Panel.In response to physician concerns and vigorous advocacy efforts by the AMA, state medical associations, and medical specialty societies, HCFA officials announced at the meeting that it has agreed to: "Add a clear note that, when a history cannot be obtained due to specific patient conditions (e.g., inability to communicate urgent, emergent situation, etc.), the history is deemed "comprehensive" for coding and documentation purposes."
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| November 1, 2006 |
| Question: Our surgeon saw a trauma patient who had a laceration repair by the ER physician and presented to our office for follow-up care. Our surgeon removed the sutures and wants to know how to report this procedure.
Answer: Suture removal may only be reported if the sutures are removed in the operating room under anesthesia (other than local), either by the physician who placed the sutures (CPT code 15850) or by a physician other than the surgeon who placed the sutures (CPT code 15851). Sutures removed in the office are either part of the 10 day global period, or in your scenario, part of the E&M service.
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| October 15, 2006 |
| Question:Our surgeon took the patient to the OR for a wound debridement and then placed a wound vac dressing. We have never reported this dressing but we see there is a CPT code, 97605, which would describe the size of the wound. Can we report both the wound debridement and the dressing?
Answer: While there is a CPT code and Medicare assigned RVUs to CPT codes 97605 and 97606 in 2006, the wound vacuum dressings cannot be reported in addition to the wound debridement codes. The only time the wound vac codes can be reported is if it is the only procedure performed at the wound site.
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| October 1, 2006 |
| Question: I was reading a coding article recently addressing the new CCI edits that went into place July 2006. It stated that beginning in July, Medicare will begin bundling conscious sedation into the sigmoid and colonoscopy codes thus will not pay separately for conscious sedation with these procedures. I am confused. I thought these codes, which have a bullseye symbol in front of them, automatically included conscious sedation, thus according to the CPT coding rules, conscious sedation could not be reported in addition to the colonoscopy and sigmoidoscopy codes. Have I been losing revenue by not billing conscious sedation in addition to the "scope" codes?
Answer:No, you were reporting the services correctly. Just because Medicare did not have a CCI edit in place does not mean that you could report the Conscious Sedation separately. Continue to follow your practice of coding according to the AMA CPT rules—which as you note, state that Conscious Sedation is included in the referenced scope codes. The author of the article must not have been aware that these codes had the bullseye symbol in front of them indicating the inclusion of Conscious Sedation in the procedure.
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| May 2, 2006 - Staged or Related Breast Procedures During a Global Period |
| Question: Our physician performed a lumpectomy with margins last week. The pathology returned positive for cancer and she took the patient to the OR for a modified radical mastectomy with axillary lymph node dissection. We reported CPT code 19160 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)) for the first procedure. What modifier do we append to CPT code 19240 (Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle)
Answer:You are correct to pay attention to global periods when performing breast biopsy and excision procedures. CPT code 19160 has a 90 day global period, thus, the return to the OR for the modified radical mastectomy is a more extensive procedure during the global period, thus meeting the requirements for modifier 58, staged or related procedure during the global period. Remember, when using modifier 58 the global period restarts and you should expect 100% reimbursement for both surgical procedures.
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| March 15, 2006 |
| Question: Our physician was called to the ER at the request of the ER physician to evaluate a patient. Following the evaluation, the physician determined he needed to take the patient to the OR for an emergency appendectomy. Can our physician report the outpatient consultation service and the appendectomy?
Answer:Yes, since your physician was asked to give his opinion regarding the evaluation and /or management of a specific problem by the ER physician, he may report the outpatient consultation codes 9924x. Since the surgeon made a decision to go to the OR after evaluating the patient, he may report 9924x-57 and the appropriate appendectomy code.The physician should dictate his note as an Outpatient consultation code and should include all work and decision making associated with that consultation in his note. This consult becomes a decision making E&M for surgery, thus the physician must append modifier 57.
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| February 15, 2006 |
| Question: Our physician recently heard that he could use both an “excision of a lesion” code and an “adjacent tissue transfer” code to report certain procedures. However, according to my understanding of the CPT book, this is incorrect. Can we use both of these codes at the same time? What is the correct way to code when the physician removes a lesion and repairs the site with a rotation flap?
Answer: You are correct, and your physician is mistaken. These codes cannot be used at the same time. The adjacent tissue transfer codes (14xxx) describe the methods used to close a defect, such as the defect that is created when a lesion is excised (for example, the excision of lesions described by the CPT code range 1144x through 1164x). According to the AMA CPT rules, when the defect is created by the removal of a lesion, the lesion removal is included in the closure, and it may not be reported separately. (Think of it this way: if you had not removed the lesion, there would be nothing to repair!)
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| February 1, 2006 |
| Question: My surgeon uses intraoperative monitoring for all of his spine surgical cases. How should I code for this monitoring?
Answer: Intraoperative monitoring is inclusive in the surgical package and should not be coded separately, according to CPT, AAOS, and Medicare.
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