The General Surgery Coding Coach 2007 Archives

Question: 

We are a new ENT practice and our physician will be placing tympanostomy tubes in the office.  We are receiving conflicting information about billing for the tubes. Some say “yes, bill”, others say “no, don’t bill”.  Can we bill for the tubes in addition to the CPT code for the placement?

Answer: 

The tympanostomy tubes themselves, as a supply, are not separately reportable as they are considered an integral part of the procedure.  The reimbursement is included in the practice expense of the non facility RVU for the tympanostomy tubes.

Question: 

A patient in our practice had a J-tube placed in February.  They presented to the office last week and the surgeon pulled the tube in the office. What CPT code is used to report the removal of the J-tube?

Answer: 

Since the patient is outside the global period, the removal of the J-tube is included in the E&M service for the day.  There is no separate CPT code for this service.

Question:

Our surgeon repaired a simple laceration with Dermabond on a Medicare patient.  I thought there was a code we could use to report this service, but I cannot find one. Can you help?

Answer:

Medicare has defined HCPCS code G0168 Wound Closure Utilizing Tissue Adhesive(s) as the only appropriate code to define wound repairs using products such as those defined as Dermabond.  Unless there is another problem, you will report using this code only.  You can expect about $27 from your Medicare fiscal intermediary. 

Question: 

We reported an excision of a scar and complex repair using the appropriate codes for the excision of benign lesion and the complex repair.  When we received the EOB, the insurance company paid the complex repair, but denied the lesion excision (in this case the scar) as bundled within the repair.  We thought you could report a repair with the excision of a lesion when the repair was an intermediate or complex repair. 

Answer:  

CPT revised the definition of this case scenario a couple of years ago. While it is correct coding to report both the excision of skin lesion and an intermediate repair, CPT revised the definition of a complex repair to include the necessary preparation to include the creation of the defect.  While scars are considered benign lesions, when the scar is excised and the size/location necessitates a complex repair, the excision is considered to be the “creation of the defect” thus is not separately reportable.   This concept applies to excision of scars and complex repairs.

Question:

Does an intermediate repair "have to" include debridement of some type? For example, according to CPT the repairs are listed with the following references:

Am I understanding this correctly?

Answer:

While a wound may require debridement of tissue (skin, subcutaneous tissue, muscle/fascia or bone), it is not a requirement to report the appropriate repair code. The reference to the debridement in the repair code means that the debridement is an inclusive or integral part of the procedure and not reported separately in addition to the repair code. CPT gives specific guidelines on which repair code is appropriate based on whether debridement is performed and the type of repair.

Our surgeon performed a partial colectomy for a patient who presented with mesenteric ischemia.  He did not perform an anastamosis but instead clipped both ends of the colon and planned a return to the OR in a few days.

How do we code the first surgery without the anastamosis and how do we code the return to the OR where he resected additional colon and then did the anastamosis?

Answer:

This is a good example of a staged surgical procedure to treat the ischemic bowel. 

The first surgery is reported 44140-52.   CPT code 44140 describes a partial colectomy with anastamosis and since the surgeon did not do the anastamosis he must append the reduced service modifier.

For the second surgery, report 44140-58.  Do not append modifier 76 as the exact same surgical procedure was not performed and this second surgery is part of the treatment plan to treat the ischemic bowel. 

Answer: This is not an atypical scenario in a patient who has positive pathology and will be receiving chemotherapy. Typically the oncologist will ask the surgeon to place a central venous access device for administration of the chemotherapy. Report the appropriate CPT code you mentioned (CPT 36561) and add a modifier 79 for an unrelated procedure during the global period.

Answer: Yes, assuming the surgeon meets the documentation requirements. She must dictate a separate (outside the body of her operative note) interpretation of the fluoroscopic guidance and she must also have a permanent recording of the procedure documenting catheter position. If she meets these requirements, she may report CPT code 77001-26 for the professional interpretation.

Answer:In order to advise the correct way to report this, additional information is required.If the excision is full thickness (that is, through the dermis), the correct series of codes will be the Excision of Benign (114xx) or Malignant Lesions (1164x). In addition to the total excision size (widest clinical diameter plus narrowest margins), you will also need to know if the lesion is benign or malignant.Or you may look at the musculoskeletal section, CPT codes 21555, Excision tumor, soft tissue of neck or thorax; subcutaneous or CPT code 21556, Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular.

Answer:Assuming the E&M is associated with examining the patient before s/he performs the colonoscopy, it is not separately billable. The surgery is pre-planned; thus the E&M is included in the payment for the colonoscopy. If the physician is evaluating and managing a second unrelated condition, the E&M with a modifier 25 may be reported in additional to the colonoscopy.

Answer:No, the service is not separately billable according to Medicare’s definition of the global surgical package. To bill for the treatment of a complication during the global period, the service must be performed in the OR, ASC, endoscopy/laser suite, or ICU if patient is critically ill and is unable to be transported to the OR. The ER, holding area, PAR, non-certified procedure room does not constitute an approved location.

Answer: You won’t find it because the CPT code is not defined as a Zenkers Diverticulum. There is no endoscopic procedure code for this procedure. Use the unlisted esophagus CPT code, 43289: Unlisted laparoscopy procedure, esophagus.

Answer: You are correct in noting that the excision of the lesion is not separately reportable and it is included in the adjacent tissue transfer. The repair of the secondary defect site is not coded separately. The surgeon would, however, sum the total size of the primary defect site (lesion site) and the secondary defect site (defect created by advancing or rotating the flap) and choose the appropriate adjacent tissue transfer code based on the sum of the two defect sizes in sq cm.For example, the defect size of the primary defect is 5 sq cm. The defect created by lifting and rotating the adjacent tissue transfer is 7 cm. Therefore, the total defect size is 12 sq cm. Thus the surgeon reports the appropriate adjacent tissue transfer code based on the size of the primary and secondary defect based on anatomic location. If the lesion and defect were on the chest, the appropriate CPT code would be 14001 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.

Answer: There are two new categories of codes in 2006 to report E&M services in an assisted Living type facility. These categories are defined by an initial patient visit (99324-99328) or an established patient visit (99334-99337).The 99324-99328 series is for domiciliary, rest home, or assisted living type facility visit for the evaluation and management of a new patient.The 99334-99337 series is for established patient visits in a domiciliary, rest home, or assisted living type facilityThe place of service according to the CPT manual is 13: Assisted Living Facility.