Endoscopic
Transnasal
Pituitary Tumor Removal
March 30, 2017
Question:
I’m confused. Should I use 61548 vs 61580 & 61600 to bill an
endoscopic transnasal approach to remove a pituitary tumor?
Or is this an unlisted code (64999)?
Answer:
Good question – there are actually 3 CPT codes that
specifically address removal of a pituitary tumor none of
which are the skull base surgery codes you asked about (61580
& 61600). They are listed in the table below:
CPT
Code
CPT Descriptor
Approach
Craniotomy for hypophysectomy
61546 or excision of pituitary tumor, Craniotomy, open
intracranial approach
61548
Hypophysectomy or excision of
pituitary tumor, transnasal or
transseptal approach,
nonstereotactic
Transnasal or
transseptal
using a
microscope
62165
Neuroendoscopy, intracranial;
with excision of pituitary
tumor, transnasal or transsphenoidal approach
Transnasal or
trans-sphenoidal
using an
endoscope
The codes, 61580 and 61600, are skull base codes which require
an open approach and are not used to report transnasal
procedures.
So there is a code for the procedure you describe and that is
62165. Remember to append modifier 62 (two surgeons) if the
approach is performed by the otolaryngologist (both surgeons
report 62165-62).
*This response is based on the best information available as
of 03/30/17.
Billing “Incident to”
March 30, 2017
Question:
Whose NPI number do we bill under when a PA sees the patient
in the office under the “incident to” rules for Medicare? We
bill under the NPI number of the physician who is assigned to
the PA. Is that correct?
Answer:
No, when billing “Incident to,” bill under the NPI number of
the physician in the office who is supervising. The guidelines
are very clear that the physician must be present in the
“office suite”. The PA’s visit must be billed under the
physician who is in the “office suite” at the time the PA is
managing the care of the patient not the physician the PA is
assigned.
*This response is based on the best information available as
of 03/30/17.
Scribe Question
March 30, 2017
Question:
In my office, we use a PA as a scribe for new patient office
visits for our doctors. We have an electronic medical record
and the scribe signs in under her own name when she begins
notating for the doctor. What is the correct way to notate in
the medical record that the PA is only acting as a scribe and
not performing the service personally?
Answer:
Good question. In order to clearly indicate what was
performed, the documentation must identify who rendered the
service and that the PA was acting solely as a scribe and did
not perform any of the services. Remember, a scribe does not
ask the patient questions or perform any examination of the
patient. Both parties need to sign the medical record
(electronically will suffice) and attest to the situation.
Noridian, the Jurisdiction E local Medicare contractor, gives
the following acceptable attestation example:
“I, _____________, am scribing for, and in the presence
of, Dr. ____________.” for the scribe; and
“I, Dr. __________, personally performed the services
described in this documentation, as scribed by
________________ in my presence, and it is both accurate
and complete.” for the physician.
Some payors only require the physician to sign the note as an
attestation and not make a separate statement (as in the
Noridian example above). You may want to check with your
payors to see if they have specific verbiage that they look
for to support the use of a scribe.
*This response is based on the best information available as
of 03/30/17.
Assistant Surgeon Payments
March 30, 2017
Question:
We are seeing payers ask for payment back when we use Modifier
80 for assistant surgeon. Is there a reason why they would
take the payment back?
Answer:
We are seeing many payers including Medicare and Medicaid ask
for payment recovery when the documentation does not explain
what role the assistant played in the surgery. It is not
enough just to identify that the patient encounter is complex
but actual detail of what the assistant did during the surgery
can support billing for an assistant surgeon.
*This response is based on the best information available as
of 03/30/17.
Percutaneous Implantation of
Neurostimulator Electrode
March 30, 2017
Question:
When reporting an epidural percutaneous implantation of a
neurostimulator electrode my physician wants to bill fluoro.
Can we bill separately for fluoroscopic guidance?
Answer:
Fluoroscopic guidance is included in implanting the
neurostimulator electrode(s) using CPT code 63650
(Percutaneous implantation of neurostimulator electrode array,
epidural). In addition 63650 includes removal of the trial
leads.
*This response is based on the best information available as
of 03/30/17.
Milia Destruction
March 30, 2017
Question:
We are confused on which code to use for a milia destruction,
Is it 10040 or 17110?
Answer:
For a milia destruction you would use 17110: CPT 17110 is
specific to benign lesions other than skin tags or cutaneous
vascular proliferative lesions. They include treatment of
proliferative cutaneous vascular lesions, flat warts,
molluscum contagiosum, or milia. Local anesthesia is included
in these services.
*This response is based on the best information available as
of 03/30/17.
Billing
Medicare
Admittance
Patient
March 30, 2017
Question:
If a Medicare patient has been admitted to the hospital as an
inpatient and the patient is transferred to my care in the ED
before they are moved to an inpatient bed, do I bill an ED
visit or an initial hospital care code when surgery is not
planned?
Answer:
Since the patient has been formally admitted you would report
CPT codes 99221-99223 for initial hospital care depending the
documentation and medical necessity for the complexity of the
patient. Keep in mind Medicare does not pay for inpatient or
outpatient consultations.
*This response is based on the best information available as
of 03/30/17.
Modifier
59
or
not
Medicare? (Response)
for
March 30, 2017
I read with interest your last coding coach on injections…
Question:
I read with interest your coding coach related to the
following scenario:
The surgeon documented a right shoulder injection with US
guidance (CPT code 20611) and a left knee injection without US
guidance (20610). Your explanation of when to use the RT/LT
and explanation of why modifiers 50, 59 and 76 were incorrect
was fantastic. But of course, I have a question about another
scenario. What if the surgeon documented the same procedures
but the shoulder and knee injections were on the same side? We
love receiving the coding coaches and fantastic information
that is provided.
Answer:
Thanks for your kind comments. Your question is a great one!
This is an example where modifier 59, distinct procedures
falls into place. Again modifier 50 (bilateral procedures)
will not work; modifier 76 (repeat procedure) will not work as
they are not the same procedure codes; the anatomic modifiers
will not work as the two procedures are on the same side of
the body. In this case, the most appropriate modifier is
modifier 59 to differentiate the injections were performed at
different anatomic joints. Let’s assume the injections were to
the right shoulder and the right knee. The coding
recommendation is as follows:
20611 RT linked to a shoulder diagnosis
20610-59, RT linked to a knee diagnosis
*This response is based on the best information available as
of 03/30/17.
Sacral Nerve Destruction
March 16, 2017
Question:
My physician performed a sacral nerve destruction at S1, S2,
S3 and S4. I am not certain how to code this. Should I report
64640 only once?
Answer:
You should report 64640 (Destruction by neurolytic agent,
other peripheral nerve or branch) for each level. You should
report 64640 x 4 (4 units).
*This response is based on the best information available as
of 03/16/17.
E/M Guidelines: How Many
Elements Make a Comprehensive
Exam?
March 16, 2017
Question:
I have a question after a recent coding/billing seminar with
Teri Romano (which was excellent!). I use the 1997 Physical
Exam Rules and am trying to figure out the required elements
for a comprehensive exam. Most information says you need 2
bullets from each of 9 organ systems. While this is easy to
understand, I noticed the guidelines also says:
Perform all elements identified by a bullet in at least nine
organ systems or body areas and document at least 2 elements
identified by a bullet from each of nine areas/systems.
I don’t understand the part underlined above. Can you please
explain this? Thank you.
Answer:
There are 15 organ systems or body areas listed in the 1997
Exam (pages 82-83); eye, neck, respiratory, cardiovascular,
etc. You need to document at least 2 in nine of the
system/body areas. Technically, the rule states that you must
perform (exam) all but you only need to document 2. You will
document the two in each system that you examined for a
medically necessary reason. In the event of an internal or
external audit, the reviewer will “count’ the number of
elements you documented. A comprehensive exam is justified if
you document 2 in at least 9 system/body areas (18 total).
If your exam typically addresses organ systems, for example,
cardiovascular, skin, respiratory, musculoskeletal, etc., you
would do better to use the 1995 Exam. If you document that you
examined at least one element in each of eight organ systems,
it justifies a comprehensive exam.
*This response is based on the best information available as
of 03/16/17.