CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Accurate coding from an operative report is often complex. Determining the optimum number of codes that can be used while remaining compliant requires a great deal of knowledge, skill and up-to-date reference sources. The following are 10 coding tips which may prove helpful.
1. Arthroscopic knee surgery
CPT code 29879 includes resection of osteophytes when performed in the same compartment. These should not be coded out separately.
Abrasion arthroplasty versus chondroplasty: Some terms that may indicate an abrasion arthroplasty was done include "detail drilling", "micro-fracturing" and "deep debridement to bleeding bone." If there is no supporting documentation, use only CPT 29877 (chondroplasty).
2. Colonoscopy
When a surgeon dictates that a polyp was biopsied and cauterized at the same time, use CPT 45384 (colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy or bipolar cautery).
However, if polyps and/or tumors are removed in different sections of the colon using different techniques during one operative procedure, more than one CPT code may be used.
Example: CPT 45384 in the ascending and CPT 45385 in the descending.
3. Hysteroscopy with polypectomy versus resection of a leiomyomata
CPT 58558 is a hysteroscopy including a polypectomy. However, the removal of a leiomyomata (CPT 58561) is a separately billable procedure with no bundling issues. Review the operative report carefully to ensure both procedures are captured if applicable.
4. Platelet-rich plasma injection
New code CPT 0232T (injection(s) platelet-rich plasma, any tissue, including image guidance, harvesting and preparation) went into effect July 1. This code is billable if it is the only procedure being performed or it is performed at different site than the surgical site. Instillation of the platelets by the surgeon into the surgical site is considered part of the total procedure and therefore this code is not applicable.
However, if a PRP injection is being done at the same surgical area, CPT 86999 (unlisted transfusion medicine procedure) can be billed when the blood draw and centrifuge is done by center staff and not an outside company or representative.
5. Double osteotomy procedures
When a combination of osteotomy procedures is performed on the phalanx and metatarsal of the same toe, this would be considered a double osteotomy and should be coded with the CPT 28299 code rather than being coded separately.
Example: If an Aiken procedure is performed on the phalanx and an Austin procedure is performed on the metatarsal, these should be coded using only 28299.
6. CPT 10060 vs. CPT 10061
CPT 10060 (incision and drainage of abscess – simple or single) or CPT 10061 (incision and drainage of abscess – complicated or multiple): How do you determine which to use?
If the surgeon leaves the incision of a simple or single abscess removal open to drain on its own, CPT 10060 should be used.
If there is need to place a drain or pack to allow for continuous drainage it may be appropriate to use CPT 10061. Make sure the operative note reflects documentation for the procedure code.
7. Surgical approach
Even the most straightforward dictation can be coded incorrectly if close attention is not paid to the surgical approach used. An easy-to-code carpal tunnel release is often coded incorrectly using CPT 64721 (open approach), when the procedure was actually done endoscopically. The endoscopic approach is coded using CPT 29848.
Be sure that you are assigning the correct code choice based on method of entry to a surgical site whether it is open, endoscopic or percutaneous.
8. Modifier -73 and -74: Know the difference
Modifier -73 — CPT guidelines state that the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed, but prior to the administration of anesthesia (local, regional block or general). This as a result of extenuating circumstances or those that threatens the well being of the patient.
The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported.
When none of the planned procedures are completed, then the first planned procedure is reported with the modifier -73. The others are not reported.
This modifier should be used to cover the expenses involved for the use of the facility.
Modifier -74 — CPT guidelines state that the physician may cancel a surgical or diagnostic procedure after the administration of anesthesia or after the procedure is started. This is a result of extenuating circumstances or those that threatens the wellbeing of the patient.
This procedure would be reported by the usual CPT code along with the modifier -74.
If this modifier is not used and the patient has to return to the center for the same procedure, then the subsequent procedure will be denied.
9. Coding for laryngoscopy: Indirect, direct or microscope used?
Laryngoscopy procedures are coded using CPT codes 31505-31579.
Procedures designated as "direct" indicate the procedure is done using an endoscope.
Procedures designated as "indirect" indicate the procedure is done with a mirror, as opposed to using the endoscope.
Procedures designated as "operative" indicate the procedure is performed under general anesthesia.
Don't forget that there are separate CPT codes for laryngoscopy done with a flexible fiberoptic scope, starting with CPT 31575.
10. Superficial sentinel lymph node biopsy
When a sentinel node biopsy (CPT 38500) is performed during the same operative session as, for example, axillary node dissection (CPT 38740-38745), the sentinel node biopsy is not billed separately.
However, if sentinel nodes are biopsied during the same operative session through a different incision, it is appropriate to bill both using the proper code, appending a -59 modifier to the second CPT code.
CPT code 38792 can be coded for the injection procedure to identify a sentinel node, and CPT code 78195-TC for related imaging. (When billable, check for bundling issues.)
If the operative report states that the injection procedure was done prior (the day before surgery) and not done at the ASC, CPT code 38792 should not be coded.
Learn more about Serbin Surgery Center Billing.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.