| Is Insertion of a Drain Reportable? |
December 17, 2009
Question:
I am new to General Surgery Coding having spent many years in Family Practice. In reviewing the operative note for a thyroidectomy, the surgeon dictated in the Procedure Title the insertion of a JP drain and the work is documented in the narrative. The surgeon made a separate incision to place the JP drain before the final closure. I cannot find a CPT code for the insertion of this drain. Is this a separately reportable service?
Answer:
No, the insertion of the drain at the surgical site is considered to be an integral part of the procedure and thus not separately reportable.
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| Delayed Closures |
December 3, 2009
Question:
Our surgeon excised a large pilonidal cyst and left the wound open and documented he planned to close the wound at a later date. His dictation in the first wound states he will have to go back to the OR for the closure. My question is when he dictated the return to the OR, do I use a modifier 58 or 78 and do I use a code from the complex repair section? It looks like he did some final exploration and irrigation, clean up before he did the repair. I looked at these codes and it looks like I will have to use a primary code and add-on code so want to make sure this is right. I am thinking modifier 78 because there is an open wound.
Answer:
This is a great question and includes many different concepts. Let’s dissect the issues:
1) Planned return to the OR based on first operative note dictation to treat the condition supports the use of Modifier 58, Staged or Related Procedure during the post op period. Modifier 78 us the unplanned/unrelated surgery modifier during the OR.
2) In your scenario and due to the nature of pilonidal cysts, he documents he will be doing a secondary closure, the correct code is 13160Secondary closure of surgical wound or dehiscence, extensive or complicated
While the repair may appear to be complex in nature, the CPT code that more closely reflects the work is CPT code 13160.
Coding Recommendation 13150-58.
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| Removal of Lumbar Drain |
November 12, 2009
Question:
What is the code for removal of a lumbar drain?
Answer:
This is not a separately billable procedure; the removal is included in the code for placement of the lumbar drain (CPT 62272).
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| How to Report the Removal of a Central Line? |
October 29, 2009
Question:
Is the removal of a central line reportable?
Answer:
If the central venous catheter is a tunneled catheter that was inserted centrally (not peripherally) and does not contain a port or pump, report CPT code 36589 Removal of tunneled central venous catheter, without subcutaneous port or pump. If the removal is performed within the global period, append the appropriate modifier. Review the CPT codes and global days to determine if the procedure for the insertion has a zero or ten day global period.
Include the work associated with the removal of the catheter was not tunneled and is not a centrally inserted catheter.
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| Laparoscopic Liver Biopsy |
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October 19, 2009
Question:
The surgeon performed a laparoscopic wedge liver biopsy due to a suspicious lesion during a laparoscopic colectomy. The surgeon submitted CPT code 47100 biopsy of liver, wedge along with the laparoscopic colectomy code. I do not think this is the correct code.
Answer:
You are correct. There is no CPT code for a laparascopic biopsy of the liver, wedge, thus the correct way to report this is with an unlisted laparoscopic CPT code. Report 47379, Unlisted laparoscopic procedure, liver.
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| Consultations in the Hospital |
October 1, 2009
Question:
Our surgeon was asked to see a patient in consultation from the internal medicine group for a possible bowel obstruction. The surgeon evaluated and worked the patient up but never went to surgery, thus no global period. We billed an inpatient consultation at that time. Now the patient has been re-admitted to the hospital six weeks later and the internal medicine doctor has consulted our surgeon again. Can we report an inpatient consultation code again?
Answer:
Yes, you will report 9925x again as the consultation codes are per hospital stay. Remember consultations have different rules than new patients and as long as all the requirements for a consultation are met, the 9925x codes may be reported one time per hospital stay.
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| What Modifier for Chemical Pleurodesis? |
September 17, 2009
Question:
Our surgeon just submitted an operative note for a patient where he dictated a “pleurodesis” six days after placing a chest tube for a pneumothorax. The patient has metastatic carcinoma. Do we use a modifier 58 or modifier 79?
Answer:
There is no modifier as the chest tube has zero global days. Thus you will report 32560, Chemical pleurodesis (eg, for recurrent or persistent pneumothorax) without a modifier.
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| Excision of Breast Lesions |
September 4, 2009
Question:
Our surgeon removed two breast lesions ,one on the right breast and one on the left breast. Do we report 19125 RT, 19125 LT or do we report 19125 RT and 19126 LT?
Answer:
The answer depends on exactly what procedures the surgeon performed. Let’s take a look at the AMA CPT description:
| 19125 |
Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion |
| 19126 |
Each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure) |
| 19120 |
Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions |
The answer to how to report this depends on whether a radiological marker had been placed preoperatively or not.
If the answer is yes, the service would be reported
19125
19126
If the surgeon had not had the lesions radiologically marked preoperatively , the surgeon would report the excision of each breast mass with CPT code 19120 as there were obviously two separate incisions.
19120
19120-59
If the payor accepts the RT (right) and LT (left) modifiers, you may append these modifiers. The most specific modifier according to the AMA CPT coding rules is modifier 59, distinct separate procedure.
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| Breast Biopsy and Mastectomy on Same Day |
August 20, 2009
Question:
Our surgeon is seeing a patient with a new left breast mass, who had a right mastectomy several years ago for breast cancer. They have discussed this new mass and have agreed to do an incisional biopsy and then, depending on pathology, will proceed as necessary with definitive surgery at the same session. Can the surgeon report the incisional biopsy and the definitive surgery on the same day if they need to do a mastectomy?
Answer:
Yes, if the pathology requires further surgical intervention, the surgeon may bill for both the biopsy and the surgical resection. In this case, there is no known pathology and the decision to proceed with definitive surgery would be based on the findings of the biopsy. Thus, both services are reportable. Per AMA CPT rules, the incisional biopsy would have a modifier 59 appended, but Medicare instructs to use modifier 58 on the biopsy on the same day.
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Diagnostic Lap—Billable or Not? |
August 7, 2009
Question:
Our surgeon performed a diagnostic laparoscopy prior to a Whipple procedure. We have told the surgeon that this is not billable as it is considered a “scout“ laparoscopy. The surgeon states the diagnostic procedure had to be performed to ensure the correct procedure was performed. The patient has had prior diagnostic work-up and this procedure was a scheduled, elective case.
Answer:
We agree with your recommendation not to bill this diagnostic laparoscopy separately. A “scout" laparoscopy, as it is known, is not separately reportable.
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|
Pain Pump Infusions |
July 23, 2009
Question:
Can our surgeon bill for the insertion of a Q Pump following a right colectomy?
Answer:
No, according to AMA CPT coding rules and Medicare, the insertion of a pain pump by the operating surgeon at the surgical site is included in the surgical procedure and not separately reportable by the operating surgeon.
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| Thoracentesis vs Chest Tube? |
July 8, 2009
Question:
Our surgeon placed a chest tube for a patient who presented with a pneumothorax. The note says the chest tube was inserted and placed to negative pressure system. Do we report CPT code 32421 or 32551? They are confusing in their definition..
Answer:
The correct code is CPT code 32551, Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure) . CPT code 32421 describes a thoracentesis for aspiration which denotes a more transient procedure.
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| Infected Joint after THR |
April 17, 2009
Question:
Our surgeon performed a right total hip arthroplasty on a patient one month ago. At this time the patient presents with a hip infection and was returned to the operating room where the physician performed an I&D of an infected joint and placed antibiotic “patties”. We are unsure how to report the work the surgeon documented. The surgeon did not remove the prosthesis.
Answer:
If the surgeon’s documentation supports a hip arthrotomy with I&D, we recommend looking at CPT code 27030 Arthrotomy, hip, with drainage (e.g., infection) plus CPT code 11981 Insertion, non-biodegradable drug delivery implant for the cement “patties.”
Both procedures would be appended with a modifier 78 and CPT code 11981 would additionally have modifier 51 appended after the modifier 78. Thus, you would submit as follows:
27030-78
11981-78, 51
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| Casting Supplies: Part of the Global Package or Not? |
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March 1, 2009
Question:
When a physician puts on a cast in the office, can we bill separately for the supplies or are the supplies part of the cast application code?
Answer:
In the office setting where the physician incurs the expense of the casting supplies, the supplies are always separately billable, whether it is the first or subsequent casts. Medicare does not include the payment for the supplies in the cast application codes, and therefore instructs the physician to use the appropriate Q codes when reporting services to their beneficiaries.
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