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1. An epidermal cyst is located beneath the skin surface and may extend into the subcutaneous tissue. When an incision is made in the skin and dissection is carried down to an epidermal cyst, this service would be reported with an integumentary system code and not a code from the anatomical section because an epidermal cyst is not a tumor.
2. An adjacent tissue transfer procedure requires the physician to make additional incisions in the skin to develop a flap after excising a lesion. When undermining is the only service performed (without additional incisions), the coder should report a CPT code from the complex repair section of the CPT manual. This is commonly seen with the terminology "advancement flaps." After excising a lesion, the physician will undermine the tissue edges and "advance" the two flaps towards each other for closure. This is an example of a complex closure and not an adjacent tissue transfer.
3. A new Category III code for platelet rich plasma injections went into effect on July 1. This procedure is represented by Category III code 0232T and includes one or more injections into "any tissue", the use of image guidance and drawing/processing the patient's blood. It would not be appropriate to use CPT codes from the 20550-20553 code range. This information also supersedes the previous article in CPT Assistant that instructed coders to report 86999.
4. A balloon sinuplasty is a procedure in which a balloon catheter is endoscopically placed across the natural sinus opening and expanded to increase or dilate the size of the opening, which is also called the natural sinus ostium. Endoscopic balloon dilation by itself is reported with unlisted CPT code 31299, but tissue removal from the ostium (and interior sinus when performed) with the use of cutting instruments allows the coder to report the endoscopic sinus surgery codes 31256-31288 and the balloon dilation then becomes an inclusive component of the endoscopic sinus procedure that is not separately reported. Note: Three new CPT codes for balloon dilation will become effective Jan. 1, 2011.
5. Bilateral procedure reporting will vary with CPT code 58661 (laparoscopic removal of adnexal structures-partial or total) depending on whether AMA or CMS guidelines are being followed. With AMA guidelines you would not append modifier -50 for a bilateral procedure or modifier -52 (reduced service) for a unilateral procedure because the CPT code definition already indicates a "partial or total" removal of the ovarie(s) and/or fallopian tube(s). Use only 58661. With CMS, 58661 has a payment status indicator of "1" for modifier -50, meaning that a 150 percent payment adjustment is made for bilateral procedures allowing the use of modifier-50 or RT/LT depending on carrier guidelines.
6. A knee arthroscopy is undertaken with the physician performing a meniscectomy and synovectomy in the medial compartment and a meniscectomy and synovectomy in the lateral compartment. It would be appropriate to report both 29880 (medial/lateral meniscectomy) and 29876-59 (synovectomy, major-2 or more compartments) for this service based on information from the AMA.
7. During the course of a colonoscopy procedure, the physician removes a polyp using snare technique. The physician locates two additional smaller polyps that are cauterized with the snare tip. The coder should only report CPT 45385. Snare tip ablation of polyps does not constitute significant extra practice expense since the same piece of equipment is used and the ablation is usually performed in conjunction with the same technique in which other polyps are removed. This is considered a convenience for the physician because a tissue sample is not necessary and the tool does not have to be changed.
8. Even though CPT 64622 indicates destruction of a nerve at the lumbar/sacral area, the coder needs to understand the anatomy and recognize the type of procedure being performed. The anatomy for the SI joint (spine and pelvic bones) differs from that of the facet joint (superior/inferior facets of the vertebra). These different joint structures also receive innervation from different types of nerves. Since the L5-S1 facet joint is similar to the facet joint anatomy located at the levels above it, CPT 64622 would be reported for nerve destruction at the L5-S1 level. The work involved for destruction of the SI joint (lateral branch nerves) is procedurally different than that described by CPT 64622, so the appropriate code would be 64640 (destruction of a peripheral nerve for each individual nerve that is destroyed). One other technique uses a single probe with multiple contacts called a Simplicity III probe. The contacts are placed across the S1-S4 nerves with all of the nerves being destroyed at the same time. This type of procedure would be reported with unlisted code 64999.
9. Facet joint injections are reported one time for each joint that is injected. Injections into the medial branch nerves differ. It takes two medial branch nerves to innervate one facet joint so injecting the L3, L4, and L5 medial branches provides a blockade to the L4-L5 and L5-S1 facet joints. In this instance, even though three injections are given, you would only report 64493 and 64494 for the two joints/levels that were treated.
10. A posterior lumbar interbody fusion is reported with CPT 22630. Bone grafting and posterior instrumentation may be utilized and would be additionally reported with the appropriate bone grafting code 20930-20938 (morcellized/ structural/allograft/autograft) and spinal instrumentation code 22840-22848. You would not report a posterior/posterolateral arthrodesis code for instrumentation and bone grafting at the same level as the interbody technique.
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