July 6, 2023 Question: A 24-year-old male is seen in our office for gynecomastia. My physician did a bilateral resection of the glandular component and liposuction of the fatty components of his defect. I am new to coding for plastic surgery and not sure how to code this. Can you help? Answer: Of course. The...
July 6, 2023 Question: My vascular surgeon partner and I performed an EVAR together. Is this reported as co-surgery? Answer: Co-surgery is defined as two surgeons doing distinct and separate parts of a single CPT code. The intent is that the two surgeons have different skill sets; be of a different surgical specialty. You and...
July 6, 2023 Question: Earlier this year, I attended an education session (not provided by KZA) where radiology reports were discussed. We have been going to KZA courses for many years and have the workbook pages with the history of the requirement and definition change for reports. We were confident we knew the documentation requirements...
July 6, 2023 Question: I have looked everywhere and cannot find a CPT code for removing a posterior nasal pack. I found CPT code 30906 for reporting control of a nasal hemorrhage when removing and replacing the pack. Can I report 30906 with Modifier 52 since my doctor is just removing the posterior nasal pack?...
July 6, 2023 Question: I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the...
July 6, 2023 Question: The surgeon performed a laparoscopic repair of an initial strangulated ventral hernia and a laparoscopic repair of an inguinal hernia on the same day. Can the surgeon bill for both procedures? Answer: Yes, both procedures can be reported with codes 49592, 49594, or 49596, depending on size, and 49650, Laparoscopy, surgical;...
July 6, 2023 Question: For a patient with a diagnosis of lumbar radiculopathy, the surgeon performed a L3-L4 laminectomy with bilateral foraminotomy. She also removed some disc at the same level. Can both 63047 and 63030-59 be billed? Answer: For a laminectomy at a single interspace/motion segment, only one code may be reported. In the...
June 22, 2023 Question: I need some guidance. A general surgeon did a left mastectomy four months ago for a patient who had breast cancer. My plastic surgeon did a breast reconstruction yesterday. What diagnosis code do I use? Answer: You would report 3 codes, the encounter for breast reconstruction following mastectomy Z42.1, Personal history...
June 22, 2023 Question: I coded a case for one of our surgeons where he did an ORIF of a distal tibia/fibula fracture (Pilon) and syndesmosis repair and documented a separate diagnosis to support each procedure. I recommended CPT code 27828 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon...
June 22, 2023 Question: My physician has started doing repairs for nasal valve collapse using low energy radiofrequency. We have been using the unlisted code 30999. Another coder told me that is no longer the correct code. Can you help? Answer: There is a new CPT code 30469 for reporting remodeling of the nasal airway...
