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Coding strategies for commonly miscoded procedures

JustCoding News: Outpatient, June 16, 2010

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by Stephanie Ellis, RN, CPC

While the coding of many surgical procedures is straightforward, some pose perplexing challenges when coders can’t locate any code or narrow the coding possibilities down to two or three codes and have difficulty making a final decision. This article will assist you with locating the correct code for these common procedures.

Removals of hardware or implants

To remove hardware or implants, the physician dissects down to visualize the implant, which is usually below the muscle level and within bone, and uses instruments to remove the implant from the bone. Use CPT® code 20680 for deep pin or other hardware removal procedures, which physicians usually perform in ambulatory surgery center (ASC) settings. Guidance from CPT Assistant June 2009 states that providers should bill code 20680 only once per fracture regardless of the number of pieces of hardware or implants the physician removes and regardless of the number of incisions the physician makes to remove the hardware.

Lipoma removals

Lipomas are benign fatty tumors, which arise in soft tissue areas, in the subcutaneous or deeper tissues. Lipomas’ depth into the tissues varies and can be as superficial as the subcutaneous tissue or extend deep into the intramuscular tissues. Therefore, you must select the appropriate code from CPT section 11400–11446 when the lipoma is located in the subcutaneous tissues and the appropriate code from the 20000 section when the physician removes the lipoma from a deep intramuscular tissue area. Coders need to know the size of the excision to correctly code these procedures.

Hammertoe repairs

Providers perform hammertoe corrections to relieve an abnormal flexion posture of the proximal interphalangeal joint of one of the toes. These procedures include any or all of the following:

  • Fixation of the toe with a Kirschner wire
  • Excision of any corns and calluses on the skin
  • Division and repair of the extensor tendon
  • Capsulotomy of the phalangeal joint

Hammertoe repairs can also involve any combination or all of the following procedures:

  • Fusion or arthrodesis procedure of the phalanx
  • Excision of the proximal phalanx
  • Capsulotomy of the phalanx
  • Associated tendon work

However, the hammertoe procedure does not include a metatarsophalangeal (MTP) joint capsulotomy done with the hammertoe procedure. Therefore, if a provider also performs an MTP joint capsulotomy, report CPT code 28270 with modifier -59 (distinct procedural service).

Retrograde pyelograms

When a physician performs a cystoscopy with a retrograde pyelogram (RPG), report CPT code 52005. This is considered a unilateral procedure, so when the physician performs an RPG bilaterally, bill it using modifier -50 (bilateral procedure) or -RT or and -LT modifiers. For RPG procedures, providers may also bill CPT imaging code 74420 for the radiologic component, although not all payers will reimburse for this code.

Bladder tumors

Physician documentation must be extremely detailed to correctly code bladder tumor procedures. These codes have special coding guidelines. Guidance in CPT Assistant August 2009 states that providers may bill only one bladder tumor code for the largest size or area of lesion that the physician removes or fulgurates, regardless of the number of tumors the physician treats or excises. For example, when a surgeon fulgurates or resects two small lesions and one large tumor, only report code 52240 once. Do not add tumor sizes together for coding. To determine which code to select, you should take into account only the measurement for each individual tumor.

Balloon sinuplasty

For balloon sinuplasty procedures, which physicians perform endoscopically to enlarge the sinus ostium opening using an inflatable device, use HCPCS code S2344 or unlisted CPT code 31299. Per CPT Assistant January 2010, these codes are not separately billable when the physician removes tissue from the same sinus. For example, when a physician performs a balloon sinuplasty on the right frontal sinus and removes polyps from that same sinus, you should only report code 31276-RT for both procedures; it is unnecessary to report codes S2344 or 31299. This applies to the same procedure performed in other sinuses.

Hernia repairs

When a physician performs a hernia repair (usually an inguinal hernia) procedure at the same time as the excision of a lesion (usually a lipoma) from the spermatic cord (same surgical case), report CPT code 55520 with modifier -59 because the 2010 CPT Manual designates this as a separate procedure. When billing an ASC claim, report HCPCS code C1781 for the hernia mesh (unless billing to Medicare, as it considers the mesh inclusive in the CPT code for the hernia repair procedure).

Sometimes a complication can develop after the implantation of mesh during hernia surgery, and physicians will need to remove the mesh at a later date. In this case, providers would either use CPT code 27087 for the removal of hernia mesh or CPT code 11005 with add-on code 11008, which is more specific for the removal of mesh, but is not covered by Medicare for ASC facilities (thus, ASCs should report code 27087 instead).

Tendon grafts with anterior cruciate ligament (ACL) repairs

The description in the 2010 CPT Manual for code 20924 for the harvest of a patellar or hamstring tendon graft specifies “from a distance.” Reporting this code with ACL repair code 29888 is not allowed when the physician obtains the tendon graft from a separate incision on the same knee. This does not constitute a far enough distance to bill for it separately, according to CPT Assistant October 1998 (even though it is not unbundled in the National Correct Coding Initiative material and the physician performs it through a separate incision). Providers may bill the tendon graft with code 20924 only when the physician obtains the graft from the opposite knee or either ankle.

Subtalar arthroereisis procedures

Do not confuse the subtalar arthrodesis fusion procedure with the subtalar arthroereisis procedure, in which a physician inserts an implant into the foot for foot pain. Use HCPCS code S2117 for the subtalar arthroereisis procedure, or bill it using unlisted code 28899. Note however that many payers, including Medicare and Blue Cross Blue Shield in many states, do not cover this procedure. ASCs should report HCPCS code S2117 for the implant used in the procedure.

Editor’s note: Stephanie Ellis, RN, CPC, is the president of Ellis Medical Consulting, Inc., in Brentwood, TN. E-mail her at sellis@ellismedical.com.

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