Category: General Surgery

Modifiers with Unlisted Codes
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Modifiers with Unlisted Codes

February 15, 2024 Question: Can I use modifiers on an unlisted code? Answer: In some circumstances, a modifier may be appropriately appended to an unlisted code. For example, CPT says, while uncommon, if multiple separately reportable unlisted codes are performed on the same patient on the same date by the same physician, multiple unlisted codes...

Biopsy Procedure
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Biopsy Procedure

December 28, 2023 Question: What is the code for an open deep left inguinal node biopsy? Answer: The correct CPT code 38531 Biopsy or excision of lymph node(s); open, inguinofemoral node(s) For biopsy or excision of the inguinofemoral (groin) nodes. *This response is based on the best information available as of 12/28/23.    

Cholecystotomy Procedure
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Cholecystotomy Procedure

December 14, 2023 Question: How should you code an open cholecystotomy, with a drain placement and a biopsy of the gallbladder wall is performed. Can the biopsy of the gallbladder be separately reported? Answer: No, the biopsy of the gallbladder wall is not separately reportable this is bundled and inclusive to the cholectstotomy. The correct...

Appendectomy with Cecum Resection
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Appendectomy with Cecum Resection

November 30, 2023 Question: As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy? Answer: No, that resection is considered part of the appendectomy procedure and not separately reported. *This response is based on the best information available as of...

Procedure
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Procedure

November 16, 2023 Question: When two surgeons work together as primary surgeons performing distinct part(s) of the procedure, and each surgeon reports his/her distinct operative work, what modifier is appended? Answer: When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should report his/her distinct operative work by adding...

POEM Procedure Coding Part 2
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POEM Procedure Coding Part 2

November 2, 2023 Question: I know the POEM procedure, is reported with code 43497, Lower esophageal myotomy, transoral (ie,perioral) endoscopic myotomy (POEM). One of our surgeon does the G-POEM procedure. This is a gastric peroral endoscopic myotomy (G-POEM) how is this reported? Answer: There is no current CPT code for this procedure. Report with an...

POEM Procedure Coding Part 1
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POEM Procedure Coding Part 1

October 19, 2023 Question: How is the POEM procedure reported? Answer: The POEM procedure, Peroral Endoscopic Myotomy, had a new code in 2022: 43497, Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]). Before January 1, 2022, it was reported using an unlisted code. Although 43497 is an endoscopic procedure, it has a 90-day global...

Billing a Cholangiogram with ICG Dye
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Billing a Cholangiogram with ICG Dye

August 17, 2023 Question: Can I report code 47563 when indocyanine green (ICG) dye is injected and then I use minimally invasive fluorescent imaging to view structures during dissection? Answer: No, it would not be correct to report code 47563 for this clinical scenario. Instead report code 47562, Laparoscopy, surgical; cholecystectomy. Although evaluation using fluorescent...

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Coding Coaches