November 1, 2018 Question: Should we append both 59 and 51 when a code is bundled and is also a subsequent procedure? Answer: Modifier 59 is only used if two codes are bundled, specifically if there is a NCCI edits for the two codes. If there is no edit, a modifier 51 is used. Over-use...
October 18, 2018 Question: Is there a specific CPT code for trauma laparotomy? Answer: No. if an exploratory laparotomy is performed and no injuries are detected and repaired, Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) is coded. If the retroperitoneum is also explores code 49010 Exploration, retroperitoneal area with or without biopsy(s)...
October 4, 2018 Question: Documentation states that the mesentery was repaired as part of where the liver was packed. How is this reported? Answer: Code 44850, Suture of mesentery (separate procedure) is designated as a separate procedure and therefore is included in the more comprehensive procedure, the liver packing. The separate procedure designation means that...
September 20, 2018 Question: What does the term “separate procedure” mean at the end of a code? Answer: Separate procedure is a confusing term. It means that the procedure is usually a component of a more complex service and is not reported in addition to the more complex service if performed in the same anatomic...
September 6, 2018 Question: How is this scenario coded? A segment of the colon is opened to remove a foreign body and then closed. No resection and no perforation. Answer: The scenario you describe is a colotomy; making an incision in the colon through which the colon is explored for biopsy or foreign body removal...
August 23, 2018 Question: Is a suture repair of the colon considered a resection? Answer: No. Suture repair of the colon (large intestine) is coded as 44604. This might be done for an injury or perforation for disease. The code include repair of a single or multiple perforation. Resection involves removing a portion of the...
August 9, 2018 Question: What is considered an operating/procedure room when billing complications with a modifier 78? Does an office procedure room count? Answer: According to Medicare, the treatment of complications is separately billable only when performed an approved operative suite which includes an OR, ASC, endoscopy or angiography suite. *This response is based on...
July 26, 2018 Question: How is installation of tPA into a chest tube coded? Answer: Report this with the following codes: CPT Code Description ⬤32561 Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up of multiloculated effusion); initial day ⬤32562 subsequent day Each of these codes is reported once...
July 12, 2018 Question: What codes are used for ligating a vessel due to a traumatic injury? Answer: See codes 37565-37618, below. Select a code based on the anatomic area of the vessel. For example, Ligation, major artery (eg, post-traumatic, rupture); neck for ligating the jugular vein. CPT Code Description 37565 Ligation, major artery...
June 28, 2018 Question: The bowel was left in discontinuity as part of damage control surgery. What do I code when I take the patient back to surgery to complete the anastomosis? Answer: When you return the patient to the OR to complete the surgery, a 58 modifier (staged procedure) will be appended to the...
