May 5, 2022 Question: We did an abdominal fat pad biopsy for primary cutaneous Amyloidosis. Would 49180 or 11104 be the appropriate code for this? Answer: 49180 is for a core sample within or behind the abdominal cavity. If the core biopsy is documented down to the subcutaneous fat pad only, this is coded as...
April 21, 2022 Question: The surgeon described the procedure as a ‘hand assisted laparoscopy”. He brought part of the bowel outside of the body for evaluation. Does this convert the procedure to open? Answer: Mobilizing the bowel outside the body (extracorporeally) during a laparoscopic procedure does not convert the procedure to open, it is still...
April 7, 2022 Question: I work with a surgeon and we see just a few Medicare patients. The surgeon believes the revised 2021 E/M guidelines will not impact our office practice because of our low Medicare volume. Is this correct? Answer: This is not correct and is a common misconception. The revised documentation requirements come...
March 24, 2022 Question: My surgeon performed all the components of a Hartmann procedure 44143 but did not create a colostomy. Can we use 44143 with a -52 modifier? Answer: The correct code for this procedure would be 44140. Code 44140 is the base code for 44143 with the only difference being a skin level...
March 10, 2022 Question: Can you bill for a wound vac on a surgical incision if the patient has a history of incision infections to help prevent this? Answer: The AMA published clarification on wound vac billing in the October 2021 CPT Assistant. Negative pressure wound therapy (97605-97606) is considered billable for both open and...
February 24, 2022 Question: My provider indicated that it took her an additional 80 minutes during a surgery to perform adhesiolysis. Is documentation of the time sufficient? Answer: Although time (specific minutes) should always be indicated in the operative note, the provider must also give the reason why the lysis took longer (what complicated this...
February 10, 2022 Question: Can I bill different diagnosis codes for conditions/problems when seeing a patient in the hospital after surgery, but during the stay of a major surgery? Answer: It depends. You cannot bill for related issues or known complications that arise from the surgery, but you can bill for unrelated conditions/problems with proper...
January 27, 2022 Question: Instead of a colostomy as described in the laparoscopic CPT codes 44208 or the open code, 44146, my doctor does a diverting ileostomy. We have been billing the primary codes 44145 or 44207 and adding the ileostomy code, 44187 if laparoscopic or 44310 if open. Is that correct? Answer: Partial colectomy...
December 30, 2021 Question: Can we bill the 92242 for the indocyanine green injection intraoperatively, for example to assess perfusion after a colectomy or other abdominal procedure? Can we bill for the injection using 15860? Answer: No, this service is included in primary surgery and not separately reported. *This response is based on the best...
December 16, 2021 Question: Since we have to bring the patients back in for COVID testing and H&P for Joint Commission, can we bill for this visit even though it’s another pre-op visit? Answer: Yes, since the original surgery was canceled and is now under consideration for rescheduling due to the pandemic and needs to...
