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The General Surgery Coding Coach 2010 Archives

Drainage of Seroma in the OR

December 23, 2010


Our surgeon returned a patient to the OR for the drainage of a seroma and drain placement two weeks post-op of a femoral bypass surgery.   How do I code for the seroma and drain placement?


There is no CPT code for the placement of the drain associated with the seroma drainage.

Look at CPT code 10140, Incision and drainage of hematoma, seroma or fluid collection as a code option based on the surgeon’s documentation.  The placement of the drain is inherent to the drainage procedure and not separately reportable.

Append modifier 78 to the appropriate surgical procedure as the patient is in the global period of the bypass surgery.

Jejunostomy Tube Placement

December 10, 2010


Our surgeon documented that he placed a jejunostomy tube for tube feeding purposes. I have looked and cannot find a code specific for the jejunosotomy.  Can you advise?  I see CPT code 44310, but it says “non-tube” and the surgeon’s documentation specific ally states a tube was placed for tube feedings. Do I have to use an unlisted code?


No, an unlisted CPT code is not necessary and you are very close to the correct CPT code! 

The answer to your question depends how the tube was placed.  Review the operative note and then look at CPT code 44300 (Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate procedure)) if performed as an open procedure.   While the code does not specifically state “jejunostomy” the generic “enterostomy” description applies to the jejunostomy.

If the surgeon placed the jejunostomy tube percutaneously with fluoroscopic guidance, look at CPT code 44941, Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.  Image guidance is not separately reportable as it is included in CPT code 44941, but the code requires documentation of the image and a separate report.

Infected Mesh Removal for Chronic Infection

November 24, 2010


Our surgeon took a patient to the OR and removed infected mesh at the site of a previous incisional hernia repair.  The patient has been treated for chronic infection and drainage and extensive wound care.  I have searched and am not able to find a CPT code.  Is there a CPT code for removal of infected mesh?


CPT code 11008 (Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure)) was revised in 2008 to include the removal of infected mesh for chronic infection.   CPT code 11008 is an add-on code, thus is reported in addition to another procedure at the same setting.

Is This a Layered or Complex Closure?

November 12, 2010


Our surgeon removed a chest wall tumor and following the resection documented the following closure: “The wound was irrigated out with saline and closed the deep tissue with 3-0 Dexon, the skin with a mixture of 4-0 nylon, 3-0 silk, and skin staples.” My question is not related to the code for the resection, but is related to the documentation for the closure.  Can you advise if the previous documentation supports an intermediate or complex closure? Is this an intermediate or complex closure?


There is no documentation of tissue undermining or advancement of skin to achieve the closure, thus it appears based on this documentation alone, it is an intermediate repair.  Intermediate repairs are included in the closure of the new soft tissue musculoskeletal codes, thus based on the documentation provided, the repair is inclusive and not separately reportable.

Conversion from Laparoscopic Hartmann Procedure to Open Procedure

Oct 29, 2010


I am reading an operative note where the surgeon began a laparoscopic procedure and after lysis of dense adhesions had to convert to an open Hartmann procedure and open mobilization of the splenic flexure.  How do I report this? 


The appropriate CPT codes based on the information provided in your inquiry are:

44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure)

If the surgeon’s documentation indicates significant additional work or time due to the initiation of the procedure laparoscopically and then conversion to an open, the use of  modifier 22, Increased Procedural Service may be warranted.  Add the diagnosis code for conversion of a laparoscopic procedure to an open as the last diagnosis code for each procedure: V64.41 Laparoscopic surgical procedure converted to open procedure.

Soft Tissue Tumor Codes and Wound Closures

Oct 14, 2010


Our surgeon is performing a complex closure for a procedure defined by one of the new soft tissue tumor codes found in the Musculoskeletal section of the CPT book.  Our surgeon stated that she was heard that we could report a complex closure in addition to the surgical resection.   We would like to verify if this is indeed true, and if so, does that mean any surgical procedure that requires complicated closure be billed separately. 


The new and revised soft tissue tumor codes brought with them very specific coding guidelines applicable to these codes only.   According to CPT 2010,”Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which may be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision.”

According to this definition, if a complex closure is required and is performed for reasons other than closure secondary to elevation of the tissue planes, the complex closure may be reported in addition to the surgical procedure.

Excision of Neuroma for Chronic Post-Operative Pain

September 30, 2010


Our surgeon has been treating a patient with chronic post-operative pain from an inguinal hernia repair two years ago.   She is planning to take the patient to the OR for the excision of a neuroma.  We need to precertify the case and are unsure what code we should use. 


Without more specific information, we cannot identify a specific code.  However, we can suggest a code range to review for the excision of a neuroma. Report the appropriate code based on the documentation of excision and anatomic location. 


Excision of neuroma; cutaneous nerve, surgically identifiable


major peripheral nerve, except sciatic


sciatic nerve


Excision of neurofibroma or neurolemmoma; cutaneous nerve

Non-Physician Provider Billing During the Global Period

September 16, 2010


Our general surgeon recently employed a nurse practitioner in the office. The nurse practitioner is seeing patients on rounds in the hospital, and she recently submitted a charge for a 99232 on a Medicare patient who was post-op total thyroidectomy. The documentation for the visit all pertained to the thyroidecotmy. Can she report this E&M service when the patient is in a global period? She says yes, because she did not assist and is not in a global period.


Great question and one of increasing concern as it relates to one of many issues related to Non-Physician Provider billing. We appreciate your attentiveness and raising the question.  While the nurse practitioner was not involved in the surgery, she is employed by the surgeon who performed the surgery; thus all visits related to the surgical procedure are included in the global period, and not reportable whether performed by the surgeon or the nurse practitioner. If the visit was for an unrelated problem that was evaluated and managed, the service would be reportable by the surgeon or the nurse practitioner, and a modifier 24 would be appended to the E&M and the appropriate unrelated diagnosis linked to the E&M.

Single Incision Surgery—unlisted or not?

September 2, 2010


Our surgeon began performing “single incision surgery,” and she wants to know if we should report this with an unlisted CPT code or if adding a modifier 22 to the CPT code is correct.  As an example, the surgeon just dictated this as a laparoscopic choleyctectomy procedure.


Thanks for your inquiry.  The number of incisions and the length of the incisions do not affect the coding of the case.  For example, MIS, or Minimal Incision Surgery has been around for many years, and the smaller incisions do not change the reporting of the procedure.  In your scenario, report the appropriate cholecystectomy code. Do not append a modifier 22, unless there were other extenuating circumstances that significantly increased the complexity of the procedure.

No global days for assistant surgeon different practice

August 19, 2010


We work with several surgeons as assistants.   When our surgeon is the assistant, we report the CPT codes with a modifier 80. Do we enter into the associated global period (typically 90 days)?  Our surgeon does not see the patient during the post operative period–should he?


This is a great question. An assistant surgeon is reimbursed for assisting on the intra-service portion of a procedure. As such, the assistant surgeon does not have a global period.   Since you are in a different group practice, your surgeon does not have a global period assigned to their work related to the service they functioned as an assistant surgeon.  There is no need for your surgeon to perform “postoperative services” as the reimbursement for the assistant does not include any postoperative care. 

Thrombectomy and thrombolysis; when can they be reported together?

August 5, 2010


As part of a percutaneous thrombectomy, I injected a bolus of tPA. Can I bill 37201 for the thrombolysis?


No.  Per CPT, intraprocedural injection (s) of a thrombolytic agent is included in a percutaneous thrombectomoy and not separately reportable.  37201, continuous infusion of thrombolytic drugs, is reportable for a subsequent or prior infusion of a thrombolytic agent. A continuous infusion means that the thrombolytic is infused through a catheter over several minutes. A bolus injection of tPA is an inclusive part of a thrombectomy and not separately reportable.

Hernias, bundled or not?

July 22, 2010


Our surgeon reported CPT codes 49505 and 49507 for repair of an initial inguinal hernia on the right and a strangulated initial hernia on the left. We put a modifier 51 on the second code, but the payor denied the service as bundled.  Is this correct?


No, it is not a correct denial. We recommend using modifier 59 instead of modifier 51 to indicate distinct separate services. The payor may think you attempted to reduce the hernia, it became strangulated, and you are trying to report two services for the same site.  If the physician’s documentation supports both services, append a modifier 59 to CPT code 49505, repair reducible, initial hernia. It is correct to report both services, however Medicare has a CCI edit in place on this code combination. Append modifier 59 indicating that the repair of the incarcerated hernia was performed on the left, and the reducible hernia was on the right side.

How do I report the work of placing a vascular closure device after an interventional procedure?

July 8, 2010


How do I report the use of a vascular closure device, such as an angioseal, placed into the arterial or venous site after an intervention?


There is no CPT code for the placement of a vascular closure device.  This is considered inclusive to the interventional procedure. Medicare has established a G code (G0269) for recording this activity, however it’s payment status in the Medicare physician’s fee schedule is as a bundled service and not separately payable.

Reporting a Thrombectomy of an AV Graft

June 24, 2010


I had a patient with a clotted forearm AV shunt. I used a catheter to dislodge the clot and then injected a bolus of tPA. Can I report the thrombectomy (36870) and the tPA injection?


36870, thrombectomy of an AV fistula, includes all mechanical and pharmacological methods employed to dissolve or dislodge the clot. The thrombolytic injection is an inclusive component of 36870 and cannot be reported separately.

Removal of Infected Infusaport

June 10, 2010


I frequently am confused when it comes to reporting the removal of infected catheters.  The surgeon documented that she removed an infected infusaport. Is this reportable with a CPT code or is it bundled in the E&M service.


The correct code for the removal of a catheter with a port or pump is CPT code  36590 (Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion).   Most of the tunneled insertion codes have a ten day global period. So you will append modifier 78 for the removal, if the patient was returned to the OR during the ten day global period. If the return to the OR was outside the ten day global period, then you do not need modifier 78.  CPT code 36590 has a ten day global period, thus if you are not in the global period of an associated procedure, you will start a new ten day global period again related to the removal procedure. 

Reporting Catheter Access to an AV Shunt in 2010

May 27, 2010


I see the 36145 is no longer in the CPT book. What do we use in its place for placing a catheter in an AV shunt for imaging and/or interventions?


CPT deleted 36145, introduction of a needle or catheter arteriovenous (AV) shunt created for dialysis. In its place, CPT has established two new codes, 36147 and 36148.  36147 is reported for the first catheter access of the AV shunt and includes all fluoroscopy (previously reported as 75790, angiography AV shunt). 36148 is reported for an additional catheter access for a therapeutic intervention. 75790 has also been deleted since it is now inclusive to 36147.

Removal of Gastrostomy Tube

May 13, 2010


Is there a CPT code for the removal of a gastrostomy tube?


There is not a specific code for the removal of a gastrostomy code.   Let’s look at a couple of scenarios.

In the office, during the global period—report 99024

In the office, outside the global period, report 9921x

If the patient is returned to the OR and the tube is removed and the gastrostomy site is surgically closed, report 43870, Closure of gastrostomy, surgical.

When can I bill for an endarterectomy with a fem-pop bypass?

April 29, 2010


In a recent coding alert, you stated that a common femoral endarterectomy could not be billed at the same time as a fem-pop bypass. When can I bill separately for an endarterectomy performed at the same operative session as a bypass?


Per CPT, “primary vascular procedures include establishing inflow and outflow by whatever procedures necessary.”  This direction applies to procedures, such as an endarterectomy, performed in vessels contiguous to the inflow and outflow vessels. So if an endarterectomy was performed in an iliac vessel or other non-contiguous vessel at the same time as a fem-pop bypass, that endarterectomy may be separately reported.

Ultrasound Billing in the Office Setting

April 15, 2010


Our new surgeon is performing fine needle aspirations in the office and wants to bill for the use of the ultrasound machine. The practice owns the machine.  Is this a separately reportable service, and if yes, how do we report this?


Yes, the service is separately reportable. The key to reporting lies in your statement that you own the equipment as this allows the practice to report the “global” radiology code.

Let’s take a look at CPT® code 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.  CPT®code 76942 without any modifiers appended is considered a global radiology code. Medicare will consider payment for radiology codes if the service is reported as a global code (without modifiers), or if the service is reported with a professional component modifier 26 for the professional interpretation, or if there is a TC modifier indicating the technical component only.

In the grid that follows, you see that payment for the global code is 5.04 RVUs.  Medicare pays the global code when the physician performs the service in the office setting and provides the professional interpretation.  In your scenario, the global payment would apply because the office owns the technology and the physician is using the technology to perform the aspiration.

Comprehensive or Global Code 76942 5.04
Professional Component 76942-26 0.94
Technical Component 76942-TC 4.10


What must be documented to support reporting the global radiology code?

To support reporting the global radiology code, the physician must own the equipment and document the following:

  • Ensure the procedure note indicates the use of the US guidance, medical necessity for US guidance, and intra-operative findings.   The fine needle aspiration is considered a surgical procedure, thus a procedure note is needed to support reporting the surgical CPT® code.
  • Print a hard copy of the US guidance film or store a digital copy on a computer or disc.
  • Professional interpretation of the US guidance, which should be kept in the medical record as a separate stand alone report (similar to the radiologist report).

How do I bill for an endarterectomy with a fem-pop bypass?

April 1, 2010


I performed a fem-pop bypass with vein and also did an endarterectomy of a severely stenosed common femoral artery.  Shouldn’t I report both procedures?


Per CPT, “primary vascular procedures include establishing inflow and outflow by whatever procedures necessary.”  Excising plaque for a diseased vessel contiguous to the bypass is considered bundled into the bypass and not separately reportable.



Aborted Surgical Procedure

March 18, 2010


Our surgeon planned for a patient to have a laparoscopic cholecystectomy. Following exploration of the area in the OR, the surgeon aborted due to significant infectious process. We reported the cholecystectomy code with a modifier 53. The patient returned to the OR this week, and we are wondering if we should use modifier 78 or 58.   What recommendation do you have?


If the case was aborted after the exploratory part of the procedure, report the laparoscopic exploration code, 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).  For the second procedure, which we assume by your question is occurring within the global period of the exploratory laparoscopy, append modifier 58 to the appropriate cholecystectomy CPT code to indicate a return to the OR for a planned/related procedure.

Use modifier 53 when the surgical procedure is aborted related to life-threatening complications.  


How do I report additional levels when I provide abdominal exposure for a spine surgeon?

March 4, 2010


I performed the exposure for a spine surgeon doing an anterior lumbar spine procedure. I know I report the spine code with a 62 modifier, as will the spine surgeon.  (See the Coding Coach from earlier this year) He performed 2 levels. Can I report the additional levels?


According to CPT, each surgeon would report the code for the initial level and any add-on codes with the 62 modifier (indicating co-surgery). So if this was a two level anterior lumbar interbody fusion, the codes for each surgeon would be:

Vascular/general surgeon

22558-62 first level

22585-62 additional level

Spine surgeon                                                 

22558-62 first level                                        

22585-62 additional level    

Billing for the HIVAMAT Therapy

February 18, 2010


I was at a meeting recently and a company representative told me I could bill Medicare for HIVAMAT therapy for swelling and pain reduction for a wide variety of patient conditions. He referenced a CMS transmittal that says the therapy using this device is billed as 91740. It sounds good but I’m skeptical.


You are right to be skeptical. The CMS transmittal referenced does not mention that "HIVAMAT therapy is considered manual therapy (which is billed as 91740)" as stated in the billing information you were given. In fact, 91740 is mentioned only incidentally in this August 3, 2006 transmittal as part of a CMS discussion on how to bill timed therapy codes.  

Per CPT, 91740 involves:  

CPT code 97140, Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, was added to CPT in 1999 to accurately report manual (soft tissue and joint) techniques. Manual therapy techniques include, but are not limited to: connective tissue massage, joint mobilization and manipulation, manual lymphatic drainage, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. As the code descriptor states "manual," providers use their hands to administer these techniques. Therefore, code 97140 describes "hands-on" therapy techniques.


HIVAMAT, as described in its consumer literature, is a pulsed electrostatic energy therapy combined with an oil-based massage. Based on the video of the product's use, the massage is minimal and probably would not meet the definition of "therapeutic" massage.

Anterior Exposure for a Spine Surgeon

February 4, 2010


I currently provide anterior exposure for spine surgeons doing an anterior lumbar interbody fusion ( ALIF) and have been coding 49000 for an exploratory laparotomy (49010 if the approach is retroperitoneal). Is this correct?


Each open surgical procedure is valued to include the approach, the repair and the closure. When providing exposure for a spine surgeon to gain access to the anterior lumbar spine, the vascular or general surgeon is providing the approach (and usually the closure) of the open spine procedure. The spine surgeon performs the repair. Each surgeon is providing a distinct part of a single CPT code (22558), which makes this co surgery per CPT rules. Both surgeons report 22558 with a 62 modifier and each must dictate their own operative note. Reporting an exploratory laparotomy code would be double billing the approach, which is inclusive to the 22558 code.

Femoral and Popliteal Angioplasty on the Same Leg

January 21, 2010


How do I bill for a femoral and popliteal angioplasty in the same leg? The CPT code says “femoral-popliteal”, does that mean I can only report 35474 once?


That depends!  If the lesion treated is a short, continuous lesion briding both vessels, a single code (35474) would be reported.  If however, angioplasties are performed on two separate and distinct lesions, for example, proximal superficial femoral and distal popliteal lesions, report 35474, and 35474-59, to indicate that two separate lesions in two separate vessels were treated.  Documentation should support the diagnostic findings and the separate location of each lesion treated. In August 2006 CPT Assistant stated “Since the inception of component coding for interventional radiology procedures, the femoral and popliteal arteries have been considered two distinct vessels. If there are distinct lesions found in both the femoral and popliteal arteries and each lesion is treated separately with transluminal balloon angioplasty, CPT code 35474 would be reported twice”.

Catheterization of the Access Vessel During Endovascular Procedures

January 7, 2010

Catheterization of the Access Vessel During Endovascular Procedures


How do I code for catheterization of the access vessel, for example the common femoral artery? Do I bill the nonselective catheterization code 36140?


Access to the common femoral artery to perform an angiogram, angioplasty , stent, etc, is not separately reported if the catheter is moved out of that access vessel. For example, if the right common femoral artery is accessed and the end point of the catheter is in the left (contralateral) superficial femoral artery, this is reported as a third order selective catheterization, 36247. The nonselective code is bundled into the selective catheterization.  If the right common femoral artery is accessed and the right superficial femoral artery is the end point of the catheter, this is reported as a first order selective catheterization, 36245.  Remember, selective catheterizations are coded based on the documented end point of the catheter. Documentation of the access vessel (puncture site) is important because it determines what catheterization code to report. The non-selective catheterization code, 36140, is reported only if the catheter is placed in the common femoral artery and not moved from that location. For example, if the catheter is placed in the right common femoral artery and a right extremity angiogram is performed with the catheter remaining in the common femoral artery, 36140 is reported as the catheterization code.

Find more Questions and Answers in the General Surgery Coding Coach Archives.

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