| Capsulotomy with Expander Exchange |
December 15, 2011
Question:
I get a lot of denials on 19370 (Open periprosthetic capsulotomy, breast) when I bill it with 11970 (Replacement of tissue expander with permanent prosthesis). Sometimes I get paid and sometimes I don’t. Have any tricks for me?
Answer:
Actually, CPT 11970 includes 19370 so the two codes should not be billed together. |
| Outside X-ray Review |
December 1, 2011
Question:
Oftentimes patients bring in their outside films (e.g., CT, MRI) for me to review as part of the office visit. Can I bill for reading these x-rays? Someone told me I could bill 76140 (Consultation on x-ray examination made elsewhere, written report) but these keep getting denied by insurance companies.
Answer:
Your review of the x-rays is included in the medical decision component of the Evaluation and Management (E&M) code you report and may not be separately reported with 76140. CPT 76140 is used for radiologists who perform a separate interpretation of x-rays performed elsewhere. |
| Selective Debridement of the Skin - How is it Coded? |
November 17, 2011
Question:
The debridement codes for skin, 11040 and 11041 are no longer in the CPT book. Does that mean debridement of the skin is no longer billable?
Answer:
The selective debridement codes were changed in 2011. CPT 11040 and 11041, previously used for debridement of partial and full thickness skin respectively, have been deleted. To report selective debridement of the skin, use 97597 and 97598.
New descriptions of the other debridement codes advise reporting 11042 for debridement of subcutaneous tissue, 11043 for muscle and/or fascia, and 11044 for bone. Also new in 2011, these codes are reported by size of debridement and have add-on codes for additional square centimeters debrided. Refer to the CPT Manual for a complete description of the appropriate use of these new/revised codes.
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| Coding Multiple Z-plasties |
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November 3, 2011
Question:
When billing for multiple Z-plasties, is the billing done by the number of Z-plasties or the total sq cm having added together each of the Z-plasty areas in sq cm?
Answer:
The coding for a Z-plasty (140xx codes) is done based on the total sq cm of the defect size and not necessarily the number of z-plasties done. So you will report one code for each defect. If there are two separate defects closed with advancement flaps (with primary and secondary defects), then report one 140xx code for each defect – or two codes.
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| Revision Breast Reconstruction |
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October 20, 2011
Question:
Is it ok to bill 19380 (Revision of reconstructed breast) and 20926 (Tissue grafts, other (eg, paratenon, fat, dermis) together for excising excess skin on the breast as well as harvesting/injecting fat into the axilla on the same side?
Answer:
No, 19380 would cover both procedures.
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| Tissue Expander Fills |
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October 6, 2011
Question:
I attended the ASPS coding course you recently taught and learned a lot of great information from you – thank you so much!
We’ve had a patient come to us who had her 1st stage breast reconstruction done by another surgeon (not in our practice) and has tissue expanders. She has not been completely expanded and is switching care to our office. I know the expansion is usually covered under the initial reconstruction and insertion but we didn’t do the initial placement. What CPT code can we use for subsequent expansion? If she requires multiple fills can we bill for each expansion? Is there a modifier we need to use?
Answer:
Thank you for you kind words – I’m glad the course was valuable to you. You are right about the expansions being included in the 90-day global period of the tissue expander placement.
If the patient is still in the global period and has switched her care to you, you are still able to bill for the expansions. However, the payor may not reimburse you since the other surgeon has been paid for the postop care.
There is not a specific CPT code for tissue expander fills. You may report an E&M code (9921x for established patient) for this service. You are not in the other surgeon’s global period so a modifier should not be necessary.
Thanks for writing to KZA and I hope to see you at an ASPS course again next year!
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| Diagnosis Code for Breast Reconstruction |
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September 22, 2011
Question:
I did an implant exchange on a Medicare patient because the old implant was many years old and had ruptured. I billed 19340 but Medicare denied the charge for “medical necessity.” What did I do wrong?
Answer:
What diagnosis code did you use? The diagnosis code is oftentimes the issue when you receive denials for “medical necessity” issues.
Question:
I used V58.42 (aftercare for surgery following neoplasm).
Answer:
OK, this is likely the reason why the procedure was denied. I recommend you use V10.3 (personal history breast cancer) and V45.71 (acquired absence of the breast and nipple) for this case as these are the diagnosis codes that payors generally recognize.
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| Post-Operative Pain Management Catheter Placement |
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September 8, 2011
Question:
We always place On-Q catheters after breast reconstruction for the patient’s post-op pain management. The vendor told us to bill 11981 (Insertion, non-biodegradable drug delivery implant). We’ve billed it like that for more than a year but are having problems getting paid by some payors. Should we keep billing for it just to see if we get paid?
Answer:
Always be careful about getting coding advice from a product vendor! In this case, the advice you’ve been given is wrong. Postoperative pain management is the surgeon’s responsibility, and included in your global surgical package for the breast reconstruction, so this service is not separately billable.
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| Co-Surgery for Breast Reconstruction |
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August 25, 2011
Question:
I recently attended the ASPS coding course you taught and learned a great deal – you are an excellent teacher! I have a coding question for a big case we are doing. The general surgeon will be performing bilateral mastectomies and I will be reconstructing with bilateral free TRAM flaps. I want to make sure I am coding this correctly – please help.
I was going to code as follows: 19364-62 (modifier 62 because done under same anesthetic as general surgeon does mastectomies) and 19364-50, 62. Is this correct?
Answer:
Thank you so much for your kind words! We pack a lot of information into the coding courses – I’m glad you found value in it.
In the scenario you describe – where the general surgeon does the mastectomies and you do the reconstruction – you do not need to append your breast reconstruction codes with modifier 62. The general surgeon will bill his/her own CPT codes for the mastectomies; you bill your own codes for the breast reconstruction.
So your codes are: 19364 and 19364-50. Remember, many payors want bilateral procedures to be reported on one line like this: 19364-50 with double your fee. Be sure to follow your payor’s specific billing guidelines.
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| Intermediate vs. Complex Repair |
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August 11, 2011
Question:
My plastic surgeon documented the following for a laceration repair procedure and wants to charge a complex repair code: “The wound was irrigated with saline and I closed the deep tissue with 3-0 Dexon, the skin with a mixture of 4-0 nylon, 3-0 silk, and skin staples.” Is this a complex repair or an intermediate repair?
Answer:
This documentation supports an intermediate repair code, not a complex repair code
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| Dermagraft Denial |
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July 28, 2011
Question:
I did a wound debridement on the leg and applied Dermagraft. I coded 15004 (surgical prep) and 15360 (application of tissue cultured allogeneic dermal substitute). Medicare denied these codes. What did I do wrong?
Answer:
Medicare instituted two new codes on January 1, 2011 for physicians to report this activity:
| G0440 |
Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less |
| G0441 |
each additional 25 sq cm |
So you’ll want to resubmit the claim using the new G code(s) and use these code(s) in the future for Medicare patients. Note that Medicare says the G codes include the site preparation and debridement so you will not separately report the surgical prep code (15004-15005).
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| Selective Debridement of the Skin. How is it coded? |
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July 14, 2011
Question:
The debridement codes for skin, 11040 and 11041 are no longer in the CPT book. Does that mean debridement of the skin is no longer billable?
Answer:
The selective debridement codes have been revamped for 2011. 11040 and 11041, previously for debridement of partial and full thickness skin respectively, have been deleted. To report selective debridement of the skin, use 97597 and 97598. New descriptions of selective debridement codes advise reporting 11042 for selective debridement of subcutaneous tissue, 11043 for muscle and/or fascia, and 11044 for bone. Also new in 2011, these codes are reported by size of debridement and have add-on codes for additional square centimeters debrided. Refer to the CPT Manual for a complete description of the appropriate use of these new/revised codes.
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| Radial Forearm Free Flap |
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June 30, 2011
Question:
Thank you for coming to our practice for an on-site coding course – we learned so much and you are an awesome teacher! I forgot to ask you a question. How do I code for a radial forearm free flap? I use the microscope when I do this so can I also charge 69990? And, what if I need to use a split thickness skin graft to close the defect – can I charge for the closure?
Answer:
Thank you so much for your kind words. I enjoyed spending the day with you and the group.
You’ve got good questions! There are three codes for microvascular free flaps:
1) 15756 Free muscle or myocutaneous flap with microvascular anastomosis,
2) 15757 Free skin flap with microvascular anastomosis, and
3) 15758 Free fascial flap with microvascular anastomosis.
Generally, 15758 is used for a radial forearm free flap but you’ll need to be sure you document whether fascia (15758), skin (15757) or muscle (15756) was used in order to choose the correct code. Use of the operating microscope is included in these three codes so do not separately report 69990.
Yes, you may separately report harvesting a graft for repair of the donor defect if you do so via a separate skin incision. So if you harvested a split thickness skin graft from the thigh to repair the forearm defect site, you’ll report 15100 (assuming the STSG is 100 sq cm or less).
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| ER Consult |
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March 31, 2011
Question:
What if the ER physician sends a patient to me, say a fracture, for evaluation. I see the patient, evaluate the fracture, treat it, and send the ER physician a letter. Is this a consult? I've been billing these as new patients, but the encounter certainly meets the criteria for a consult.
Answer:
These are not consults - these are new patients so you've been doing it right! There is no mandate to send the ER doctor a letter. This is a transfer of care because the ER doctor is not going to use your information for ongoing coordination of care for that patient (the ER dr hopes never to see that patient again!). This is basically a self-referred patient (9920x).
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| ER Consult |
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March 17, 2011
Question:
When one is called to the ER by the ER physician, and evaluates the patient, a consult code is reportable, even though there is a transfer of care, true?
Answer:
Yes this is a consult (9924x) because you went to the ER and did not know prior to that service that you would accept the patient.
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