Assigning the correct Current Procedural Terminology (CPT)* code for procedures and services is an important aspect of surgical practice. This column responds to several frequently asked questions posed to the American College of Surgeons’ Coding Hotline.
My group practice has both general surgeons and colorectal surgeons. If a general surgeon in the practice performs a hernia repair on a patient and, six months later, a colorectal surgeon in the practice sees a patient with complaints of bright red blood in stool, is the patient new or established for the colorectal surgeon?
The colorectal surgeon would report the patient as a new patient if the surgeon’s specialty designation in the Medicare/payor file is colorectal surgery. However, if the surgeon’s specialty designation is general surgery (even though the surgeon primarily performs colon and rectal procedures), then the patient would be considered established. It is important that all surgeons know their specialty designation with Medicare and other payors. Keep in mind that a surgeon does not need to be board certified in a specialty to designate a specialty for Medicare. The designation should represent most of the surgeon’s caseload. Also, be aware that Medicare does not have a designation for every specialty. For example, Medicare has no specialty designation for breast surgery, bariatric surgery, or hepatobiliary surgery. For each of these practice foci, the surgeon would most likely choose general surgery or surgical oncology.
Surgeons can verify their Medicare enrollment details and specialty status using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).
Should I append modifier 57, Decision for surgery, to an office evaluation and management (E/M) service if the visit occurred two months before the scheduled surgery?
Only append modifier 57 to an office visit E/M code when the decision for surgery visit occurs the day of or the day before a 90-day global major operation. Major surgical procedures include all of the E/M services performed the day of or the day before the procedure, unless it is the visit at which the decision for surgery was made. If the procedure has a 0-day or 10-day global assignment, it is considered a minor operation (or endoscopy) and modifier 57 would not apply.
Code 76001, Fluoroscopy, physician or other qualified health care professional time more than 1 hour, assisting a nonradiologic physician or other qualified health care professional (eg, nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy), was deleted for 2019. What code should we use to report this service?
Code 76001 was deleted because of very low volume and possible misreporting. Code 76000, Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time, is still available for reporting fluoroscopy services.
What is the code for an open deep left inguinal node biopsy?
Report code 38531, Biopsy or excision of lymph node(s); open, inguinofemoral node(s), which was newly added to CPT in 2019.
The surgeon performed a nipple-sparing mastectomy on the right breast of a patient two years ago. The patient now is undergoing a mastectomy of the left breast, and the surgeon also prophylactically is removing the nipple from the right breast. Is removal of the nipple from the right breast reported with code 19303, Mastectomy, simple, complete, or 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)?
Code 19303 includes removal of all breast tissue regardless of whether skin and/or nipple is retained. Code 19301 also includes removal of breast tissue. Removal of the nipple and skin at a later date is not removing breast tissue; therefore, it would be incorrect to report either 19303 or 19301. This procedure should be reported with 19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions.
How do you know if an axillary lymph node is superficial or deep when choosing to report code 38500, Biopsy or excision of lymph node(s); open, superficial, or 38525, Biopsy or excision of lymph node(s); open, deep axillary node(s)?
Clinicians divide axillary lymph nodes into three levels. Level II and III lymph nodes are always deep and reported with 38525. Level I nodes may be either deep (reported with 38525) or superficial (38500), depending on the individual patient. For coding purposes, superficial nodes (38500) are generally palpable and deep nodes (38535) are generally nonpalpable. Also consider that deep nodes are reached after crossing a fascial plane (clavipectoral fascia in axilla). Superficial nodes are above the fascial plan and typically easily palpable.
Can code 15777 be reported when a surgeon applies EpiFix to the anastomosis after a partial colectomy?
No, code 15777, Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure), is meant for reporting fascial/integumentary soft tissue reinforcement—not for reinforcement of a colon anastomosis. This novel technique is considered experimental and not separately reportable.
How do I report suture ligation of parastomal varices?
Report code 37799, Unlisted procedure, vascular surgery, and crosswalk the value to a vessel repair code.
What are the correct codes to report a laparoscopic Heller-type esophagomyotomy with Endoflip when performed in a facility?
Report code 43279, Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed, and 91040–26, Esophageal balloon distension study, diagnostic, with provocation when performed. Modifier 26, Professional component, is appended to 91040 because the technical component is reimbursed in a fee paid to the facility, not to the physician.
Contact the Coding Hotline
The ACS—as a part of its ongoing endeavor to support Fellows—has established a coding consultation service hotline. ACS Fellows may call the Coding Hotline for answers to questions related to CPT; Healthcare Common Procedure Coding System; International Classification of Diseases, Tenth Revision Clinical Modification codes; and global fee periods. To access a coding specialist, call 800-ACS-7911 (800-227-7911) 8:00 am to 5:00 pm Central time, excluding holidays and weekends.
*All specific references to CPT codes and descriptions are © 2018 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.