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Coding

Table of Contents

Introduction

  • CPT = Current Procedural Terminology 
  • Maintained and copyrighted by the American Medical Association (AMA) 
  • Designed to communicate uniform information about medical services and procedures 
  • New editions released each October 

CPT Code Modifiers

Purpose of modifiers

  • Indicate a service or procedure has been altered in some specific circumstance, but has not changed in its definition or code 
  • Applies to major procedures within a 90 day post-operative period and minor procedures within a 10 day post-operative period 
  • All modifiers are listed with the abbreviated description on the inside of the CPT book 
    • More detailed description in Appendix A of the same 

Types of modifiers

Pricing ModifiersPayment Eligible ModifiersLocation Modifiers

When the work required is substantially greater than typically required 

  • Documentation within the operative report must reflect this increased difficulty 

Unless the CPT code itself is defined in the CPT code itself 

  • 64650 – Chemodenervation of eccrine glands; both axillae 

A service may be partially reduced or eliminated at the discretion of the physician 

Used when a procedure is started but discontinued due to extenuating circumstances or those that threaten the well-being/safety of the patient 

Used with two surgeons perform different parts of a procedure, but there is only one code to report for the procedure/service performed 

Each surgeon must dictate the portions of the procedure that they performed and each would report the associated code with the –62 modifier 

An assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon.

Provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated.

Codes for an assistant surgeon when a qualified resident is not available (primarily used at teaching hospitals)

Unrelated evaluation and management (E/M) service by the same physician during a post-operative period 

Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service 

Example: 

  • A patient presents to a Hand Surgeon in for hand pain. They are diagnosed with arthritis and undergo a steroid injection at the same appointment. This appointment would be coded with a “-25” modifier and then coded for an injection. If the patient had been scheduled for the injection initially, the visit would only be coded for the injection rather than the  consultation. 

If multiple procedures other than E/M or PM&R services are performed at the same session by the same provider, the secondary or subsequent codes may be identified by appending “-51” with the exception of “add-on” codes 

  • “Add-on” codes are usually identified with a “+” or a circle with a back-slash through it meaning modifier -51 exempt 

E/M day before or day of major surgery that resulted in initial decision to perform the surgical procedure

  • For example, a surgeon sees a patient and determines that urgent major surgery (a procedure that assigns a 90-day global period) is appropriate and medically necessary (and their documentation clearly states this).  The E/M is not bundled into the surgery payment and is billed/paid separately.
  • This does not apply for the decision to perform minor procedures (those with 0-10 day global periods).

Pertains to a staged or related procedure as that previously performed within the preceding post-operative time period 

This modifier indicates that the procedure was either planned or anticipated (staged) to take place during the post-operative period or that secondary procedure was more extensive than the original procedure performed 

Modifier to indicate that a given procedure is separate from and should not be bundled into other non-E/M services 

Pertains to an unplanned return to the OR for reason related to the initial procedure (i.e. a complication) during the post-operative period  

When an unplanned return to OR within the post-op period is for a reason that is unrelated to the initial procedure 

LT 

Left side 

RT 

Right Side 

E1 

Upper, left eyelid 

E2 

Lower, left eyelid 

E3 

Upper, right eyelid 

E4 

Lower, right eyelid 

FA 

Left thumb 

F1 

Left second finger 

F2 

Left third finger 

F3 

Left fourth finger 

F4 

Left fifth finger 

F5 

Right thumb 

F6 

Right second finger 

F7  

Right third finger 

F8 

Right fourth finger 

F9 

Right fifth finger 

TA 

Left great toe 

T1 

Left second toe 

T2 

Left third toe 

T3 

Left fourth toe 

T4 

Left fifth toe 

T5 

Right great toe 

T6 

Right second toe 

T7  

Right third toe 

T8 

Right fourth toe 

T9 

Right fifth toe 

 

Order of Reporting Modifiers

  • Proper sequencing of modifiers help prevent delay of payment for a claim 
  • Report pricing modifiers before payment modifiers and location modifiers 
    • EXCEPTION: When the global surgery package is involved, report payment modifiers before pricing 
      • EXAMPLE: Unplanned return to the OR (modifier –78) and two surgeons (modifier –62) 
  • Location modifiers are always last 

Special Situations

Lacerations

  • Include: 
    • Length, location and depth of each laceration  
    • If debridement performed 
    • If closed in layers 
  • Multiple lacerations in the same anatomic area will be summed together to yield an overall length for a given area 
Skin Lesion Excision 
  • Code based on the total dimension of the area excised (e.g. margin + lesion + margin), not the size of the lesion 
    • BUT, the margins chosen for coding are those that are the NARROWEST margins for excision of the lesion 
    • Even though it may be necessary to extend the excision as an ellipse to allow for smooth closure, it is not important to code by the longest dimension of the defect 
  • Based on anatomic sites of the excision and depth of mass 
  • Radical resection codes should not be used for primary skin tumors such as melanoma 
  • Unlike laceration repairs where total length can be combined in one area, lesions are always coded separately regardless of whether or not they are in the same area
  • Closure 
    • Always specify if the wound was closed in layers
  • Flap Closure 
    • If an adjacent tissue rearrangement is performed for closure, it is coded by the area of the flap + are of primary defect 
    • It includes excision of the lesion and this should not be coded separately

Scars & Keloids

  • Document if the scar or keloid is obstructing an orifice, causing a functional impairment, pain, itching, or may be causing wound drainage 
  • These are the only two diagnoses that Medicaid requires authorization for 
  • Must book procedures for scars or keloids with one of these diagnoses so that pre-authorization can be obtained 
Muscle or Tendon Repairs
  • Must specify affected limb and part of limb  
  • Upper arm/forearm 
  • Upper leg/lower leg 

Open Fractures

  • In order to use debridement in “open fracture” or “open dislocation,” must include the word OPEN 
  • Even if it is obvious (e.g. hand blown off), must state that it is an open fracture/dislocation 

Digital Amputations

  • Include the joint level of amputation and if any local flaps were created to close the wound 

Reduction Mammoplasty 

  • Be sure to dictate the supporting diagnoses in addition to breast hypertrophy 

Nipple Tattoo

  • Do not use a bilateral modifier 
  • Just sum the total square cm of tissue tattooed 
  • Per ASPS, when performed within the global period and performed in the office, should not be coded and billed 

Panniculectomy

  • Typical panniculectomy coverage requires that:
    • The pannus hangs below the level of the pubis 
    • The pannus is the primary cause of skin conditions (intertrigo) requiring antibiotics or skin ulcerations that require treatment 
    • Surgery is expected to restore or improve functional impairment 
    • The pannus interferes with daily living activities 
    • Weight after bariatric surgery must stabilize 12-18 months after surgery and remain stable for at least 6 months 
  • It is not considered reconstructive when performed in conjunction with abdominal or gynecologic surgery (e.g. hernia repair), unless above criteria are also met 

Congenital Ear Reconstruction 

  • Ear Molding 
    • 21086 – Impression and custom preparation, molding of ear 
  • Otoplasty for Prominent/Protruding Ear 
    • For ear reshaping 
    • Often, not covered by insurance 
    • If used for Stahl’s or constriction, get pre-authorization 
    • 69300 – Otoplasty – protruding ear, with or without size reduction  
  • Microtia Reconstruction 
    • No specific codes exist 
      • Implant-based reconstruction  
        • Begins with excision of vestigial ear: 
          • 69110 – Excision of external ear; partial, simple repair 
        • Mastoid-skin dissection for pocket formation: 
          • 14061 – Adjacent tissue transfer 
            • Use –52 reduced service modifier 
          • If temporal-parietal flap is elevated, use 15732 
        • Implant placement 
          • 21208  
      • If tissue expander is placed: 
        • 11960 – Tissue expander placement and all subsequent expansions 
        • 11971 – Removal of tissue expander 
      • Autologous reconstruction  
        • Rib reconstruction 
          • 21230 – Harvest of rib cartilage for ear 
            • Report each additional rib separately 
        • Sculpting of framework 
          • 69399 – Unlisted ear procedure – detailed sculpting of ear cartilage framework 
        • Dissecting the tissue pocket 
          • 14061 – Adjacent tissue transfer 
            • Use –52 reduced service modifier unless earlobe transposition is performed simultaneously, then report only 14061 without modifier 
        • Separate stage earlobe transposition 
          • 14060 – adjacent tissue transfer (z-plasty) 
        • Tragal reconstruction  
          • 21235 – if ear cartilage graft harvested 
          • 15760 – if composite graft harvested 
        • Elevation of cartilage framework 
          • 15576 – chondral cutaneous flap 
        • Skin grafting of post-auricular sulcus 
          • 15120 – if STSG 
          • 15260 – if FTSG 
        • Augmentation of mastoid for ear projection 
          • 21230 – if using rib cartilage 
          • 21208 – if using hydroxyapatite blocks 

Office Visits

  • New Patient = A patient that has never been seen by you or has not been seen for more than 3 years 
  • Consultation = Requires a request by another physician to have been made 
  • Visit = If the encounter is initiated by the patient 
    • Regardless if your general practice is to call an initial visit a consultation or if the primary purpose of the encounter to work-up a problem and make a clinical decision 

RVU

  • RVU = Relative Value Unit 
  • A unit of measure designed to represent a CPT code 
  • A CPT code consists of three RVU components: 
    • Work RVU 
    • Practice Expense (PE) RVU 
    • Malpractice Expense (MP) RVU 
  • Physician’s fees are determined by multiplying the work RVUs by a conversion factor which is determined on by the Geographic Practice Cost Indices 
  • Some code sets (I.e. cosmetic) have no RVU value 

Procedural Dictation

Guidelines

  • In all surgical cases, be anatomically specific in the pre- and post-operative diagnoses 
  • Report co-morbid conditions that can affect the surgical outcome 
  • All surgeons involved in the case should be identified by name, degree, specialty and standing 
  • A statement justifying the presence of a second surgeon should be included in the indications for surgery 
  • Always mention the particulars that may justify increased re-imbursement 
  • The body of the operative report must mention all of the procedures listed in the header section 
  • Symmetric procedures must have separate dictations 
    • One sentence to indicate an identical procedure was performed on the contralateral side is insufficient 
  • Some difficult wound closures may be billable 
    • Include details of length, location and type of closure 
  • Indicate if the operating microscope was used 
  • For breast procedures, describe what was done to the capsule 
  • List all diagnoses pertinent to that procedure 
  • Delineate operative findings in the post-operative diagnoses 
  • The goal is to create an operative report that provides all necessary details for surgery an can stand alone during any appeals process 

Global Surgical Package

  • With regards to major procedures, it includes: 
    • All services for 24 hours prior to the procedure 
    • The history and physical exam 
    • Informed consent discussions 
    • 90 days of uncomplicated post-operative care 
  • What is NOT included: 
    • The initial visit 
    • Any subsequent visits until the decision for surgery is made 
    • Any post-operative visits beyond the 90 day period 

Unbundling

  • It’s similar to coding an incidental procedure, but is usually less subtle fragmenting of a bill 
  • Never divide the components of a procedure when one code covers all of them 
  • Examples: 
    • Location infiltration of medication 
    • Closure of surgically created wounds, minor debridement, wound culture 
    • Exploration of an operative area 
    • Lysis of moderate amounts of adhesions 
    • Fulguration of bleeding points 
    • Application of dressings (including VACs such as if used over a skin graft) 
    • Application of splints with musculoskeletal procedures 
    • Debridement when performing a skin graft 
      • Instead use surgical preparation of recipient site