Coding 10-22 Flashcards
A 46-year-old woman underwent immediate tissue expander/implant-based breast reconstruction after right mastectomy. Postoperatively adjuvant chemotherapy or radiation therapy are not required. Two months later, the patient has completed the expansion process, is happy with her current breast size, and would like to move forward with placement of permanent implants. In addition to the primary code for exchange of expander for permanent implant, which of the following CPT modifiers must be added to ensure payment of the second-stage procedure during her initial global period?
A) -22
B) -50
C) -57
D) -58
E) -62
The correct response is Option D.
Staged procedures performed on the same operative site and within the standard 90-day global period require the -58 modifier to indicate that the procedure was either planned or anticipated, was more extensive than the original procedure, or needed for therapy following or related to the original procedure. Procedures that are not designated with the modifier -58 may not be authorized and/or reimbursed, since major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge.
Modifier -22 is used to denote increased procedural services when the performed surgery required significantly more effort and/or was more difficult than the planned procedure, and supporting documentation is provided to justify why this was the case. Modifier -50 is used to denote bilateral procedures where this is applicable. Modifier -57 is associated with urgent or emergent procedures, and it is typically appended to the evaluation and management code after the provider evaluates the patient and determines that surgery must be performed either that day or the next day. This allows the provider to bill for both the procedure as well as the evaluation and management service so that the two are not bundled into the global surgery payment. Modifier -62 denotes two surgeons working together as primary surgeons, which was not applicable in this case.
A 23-year-old man comes to the clinic with a prominent sternum and anterior protrusion of the costal cartilages. He has no cardiopulmonary concerns but is bothered by the aesthetic appearance of the chest. The plastic surgeon plans to correct this deformity with splitting of the pectoralis major muscles, resection of the cartilage, and plating with bioresorbable materials. Which of the following is the most appropriate CPT coding for this repair?
A) 21740 (reconstructive repair of pectus excavatum or carinatum, open)
B) 21740 (reconstructive repair of pectus excavatum or carinatum, open) and 21600 (excision of rib, partial)
C) 21742 (reconstructive repair of pectus excavatum or carinatum; minimally invasive approach, without thoracoscopy)
D) 21742 (reconstructive repair of pectus excavatum or carinatum; minimally invasive approach, without thoracoscopy) and 21600 (excision of rib, partial)
E) 21743 (reconstructive repair of pectus excavatum or carinatum; minimally invasive approach, with thoracoscopy)
The correct response is Option A.
The most appropriate CPT coding for correction of pectus carinatum is 21740.
CPT code 21740 includes the surgical approach, costal cartilage resection, osteotomies, internal fixation, and soft-tissue closure. CPT code 21600 is not reported separately, since this would be unbundling. CPT codes 21742 and 21743 refer to the minimally-invasive approaches, with and without thoracoscopy, respectively.
A 42-year-old man is referred to the office for evaluation and treatment of a 1.2-cm skin lesion of the volar forearm after being evaluated by a dermatologist. The lesion appears benign, and excision with closure is performed with local anesthesia as an outpatient procedure (CPT 11402). The patient is seen postoperatively at 7 days and 8 weeks. According to Medicare global surgery payment procedures, which of the following is the length of the global period for this procedure?
A) 0 days
B) 7 days
C) 10 days
D) 14 days
E) 30 days
The correct response is Option C.
The global surgical package, also called global surgery, includes all the necessary services normally provided pre-, intra-, and postoperatively. Surgical CPT codes cover care provided in the global period, which may be days or months, depending on the procedure. The global period is 90 days for many operative procedures performed by plastic surgeons, but may be as short as 10 days for minor procedures (such as in the case presented).
Services included in the global surgery payment include:
Preoperative visits after the decision is made to operate
Intraoperative services
All additional medical or surgical services required during the postoperative period because of complications, which do not require a return to the operating room
Follow-up visits during the global period (which for the case presented [a minor procedure] would be 10 days; therefore, a postoperative clinic visit at 8 weeks is not within the global period)
Postoperative pain management
Routine supplies
Miscellaneous services, e.g., dressing changes, etc.
Services not included in the global surgery payment include:
Initial consultation to determine the need for major surgery; the initiation evaluation for minor surgical procedures (such as the case presented) is included in the global surgery package
Diagnostic tests and procedures, including diagnostic radiologic procedures
Services of other physicians related to the surgery
Treatment for postoperative complications requiring a return trip to the operating room
0, 7, 14, and 30 days all represent incorrect responses and do not represent the global period associated with the minor procedure presented here.
A 35-year-man with a history of below-knee amputation comes to the office for chronic pain on the lateral portion of the amputation stump. He is diagnosed with a common peroneal neuroma. Targeted muscle reinnervation (TMR) transferring the transected peripheral nerves to recipient motor nerves of residual muscle to reestablish muscle innervation is planned. Which of the following CPT codes is most appropriate for this procedure?
A) 64708: Neuroplasty of major peripheral nerve
B) 64772: Transection of other spinal nerve
C) 64787: Burial of neuroma in muscle
D) 64859: Suture of major peripheral nerve
E) 64905: Nerve pedicle transfer; first stage
The correct response is Option E.
The targeted muscle reinnervation procedure involves transecting a sensory or mixed motor nerve and transferring it in an end-to-end fashion to the smaller motor nerve in a nearby muscle. Since the surgeon is connecting two different nerves together, this is treated as a nerve transfer procedure. The suture of a major peripheral nerve is used to code for a repair of a laceration of nerve. While the common peroneal neuroma is being transected, the proximal stump of the nerve is not being buried in an innervated muscle; therefore, the burial of the neuroma code is not appropriate. Also, while the surgeon is transecting the common peroneal nerve to resect the neuroma, the transection code cannot be billed, since it would be included in the nerve transfer code. Also, the neuroplasty code is bundled in the nerve transfer code under normal circumstances.
A 33-year-old transfeminine (male-to-female) patient with gender dysphoria presents for consultation regarding bilateral breast enlargement with silicone implants. Which of the following is the most appropriate CPT code for this procedure?
A) 19324-50: mammaplasty, augmentation; without prosthetic implant
B) 19325-50: mammaplasty, augmentation; with prosthetic implant
C) 19342-50: delayed insertion of prosthesis in breast reconstruction
D) 19357-50: immediate insertion of a tissue expander
E) 19366-50: breast reconstruction with other technique
The correct response is Option B.
Breast surgery for treatment of gender dysphoria is a recognized therapeutic option, which is covered by the Centers for Medicaid and Medicare Services, military health maintenance organizations, and most private payers. Because breast reconstruction with implants is a defined, covered benefit for women with breast cancer, as mandated by federal legislation, the US judicial system has ruled that this procedure should also be available to transgender women who desire breast reconstruction. Because this benefit is available for some women, this benefit should be available for all women, including transgender women. Withholding a medically necessary procedure for treatment of gender dysphoria would represent a form of gender discrimination.
The CPT code recognized by both private and public health insurance companies is 19325-50 for bilateral augmentation mammoplasty with prosthetic implant. Even though this code is most often used in the aesthetic setting, the procedure is considered to be reconstructive in transgender women with gender dysphoria.
A 43-year-old woman comes to the office for postoperative care 3 weeks after reconstruction of the left breast with placement of a tissue expander. Localized seroma is palpated just above the inframammary fold. The seroma is aspirated, and the expander is instilled with 90 mL of saline solution. Which of the following is the most appropriate CPT billing description for this office visit?
A) Level II new patient visit for new problem of seroma
B) Level III established patient office visit
C) Percutaneous seroma drainage and expander filling
D) Percutaneous seroma drainage only
E) Postoperative visit
The correct response is Option E.
Tissue expander reconstruction is a major operation for which a 90-day global period is included in the operation. During such time, all postoperative care is included in the operative service and no additional fees are payable. The exception is for a return to the operating room for complications such as hematoma or infection. Expansion and percutaneous seroma drainage are both part of routine care and cannot be billed for during the 90-day global period. The patient billing code for the visit is for postoperative visit 99024.
A 52-year-old woman is undergoing Stage II alloplastic breast reconstruction. The surgeon opens the breast pocket by excising the mastectomy scar, divides the muscle and expander capsule, removes the tissue expanders bilaterally, places silicone high-profile implants, and closes the 7-cm incision in layers. The surgeon then performs fat grafting for correction of medial hollowness. Which of the following is the most appropriate CPT coding for this procedure?
CPT CodeDescription
A) 19380Revision of reconstructed breast
B) 11970, 19370,
20926, 13102Replacement of tissue expander with permanent prosthesis, Capsulotomy, Fat grafting, Complex repair
C) 11970, 20926,
13102Replacement of tissue expander with permanent prosthesis, Fat grafting, Complex repair
D) 11970, 20926Replacement of tissue expander with permanent prosthesis, Fat grafting
E) 11970, 19370Replacement of tissue expander with permanent prosthesis, Capsulotomy
The correct response is Option D.
This patient’s procedure should be coded as replacement of tissue expander with permanent prosthesis (11970) and fat grafting (20926). Excising the mastectomy scar, often performed prior to closure, is bundled in 11970. In this scenario, periprosthetic capsulotomy is not a separate code because the capsule was incised as the approach to the implant. The revision of reconstructed breast code (19380) should only be used in a patient who is undergoing the revision of a preexisting reconstruction and not a patient undergoing Stage II alloplastic reconstruction.
A 55-year-old woman has a 3-cm defect after excision of a basal cell carcinoma. A nasolabial flap is elevated, rotated, and inset into the lip defect. Photographs are shown. Plans are made to divide and inset the base of the flap, which contains the pedicle, in 3 weeks. In addition to CPT code 11643 (excision of malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm), which of the following is the most appropriate CPT code for this procedure?
A) 13152
B) 14060
C) 15576
D) 15732
E) 15740
The correct response is Option C.
The correct CPT code is 15576, formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral. CPT codes 15570 to 15650 are used to describe distant pedicled skin flaps, in contrast to adjacent tissue flaps. The nasolabial flap is a pedicled flap based on the angular branch of the facial artery. Although the nasolabial flap comes from the cheek, the correct code for this situation is based on the recipient site (lip) when the flap is attached in transfer. If this flap were elevated but delayed, then the code would be based on the donor site (15620, formation of direct or tubed pedicle, with or without transfer, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet).
Complex repairs do not involve the formation of a pedicled flap and do not create a donor site, although they do include undermining. Adjacent tissue transfer involves movement of tissue directly adjacent to the flap, such as in rotation flaps or transposition flaps. Adjacent tissue transfers are usually not staged procedures, while distant flaps (15570-15650) are often staged. The nasolabial flap is not a muscle, myocutaneous or fasciocutaneous flap. Examples of flaps included in the 15732 code include temporalis muscle flaps, temporoparietal fascia flaps, and sternocleidomastoid muscle flaps. Island pedicle flaps are cutaneous flaps transposed into a nearby but not immediately adjacent defect, with a pedicle that incorporates an anatomically named axial vessel, and are transferred through a tunnel underneath the skin and sutured into the recipient site defect. While some nasolabial flap reconstructions are performed as island pedicle flaps, this one was not. The pedicle was left intact and division was planned at a later stage. Note that codes for excision of the basal cell cancer cannot be used in conjunction with adjacent tissue transfer (14XXX) or complex repair (131XX) series of codes.
A 55-year-old woman undergoes unilateral breast reconstruction using a deep inferior epigastric artery perforator (DIEP) flap. After the mastectomy, the skin flaps appear dusky. You perform intraoperative indocyanine-green angiography to assess perfusion of the mastectomy flaps and the DIEP flap. Rib resection is performed and the patient’s internal mammary vessels are prepared as the perforator flap is harvested. Anastomosis is performed under the microscope and the abdomen is closed. Which of the following are the most appropriate current procedural terminology (CPT) codes for this case?
A) 15860, 19364
B) 19364, 21600
C) 19364, 92240
D) 15860, 19364, 21600
E) 19364, 21600, 99240
The correct response is Option A.
Partial rib resection (21600) is bundled within the 19364 code. 92240 is the code used for indocyanine green in retinal surgery, so is inappropriate. 15860 is the most appropriate code for assessing flap perfusion with indocyanine green. This code can be reported separately from the free flap code.
A 43-year-old woman undergoes implant exchange and fat grafting 3 months after full expansion. Intraoperatively, complete capsulectomy is performed because of the thickness and position of the capsule. Which of the following is the correct current procedural terminology (CPT) code for this case?
A) 11970 and 20926
B) 19342 and 20926
C) 19371 and 11970
D) 19328, 19342, and 20926
E) 19371, 11970, and 20926
The correct response is Option E.
The current procedural terminology (CPT) code 11970 includes the capsulotomy as the approach to the tissue expander but does not include the total capsulectomy, 19371, which is separately reportable. Fat grafting is also reported separately from the tissue expander replacement, 20926. Alternatively, this could be reported as a single code, 19342, which includes removal of the tissue expander, replacement with permanent prosthesis, capsulectomy, capsular adjustments, fat grafting and other necessary adjustments. If this one code is used, then using the additional codes of 19328 and 20926 separately would be considered unbundling.
A 41-year-old woman comes to the office for follow-up examination after undergoing reconstruction of the left breast with an implant. She has an upper pole contour depression and desires correction. She has been preauthorized for fat grafting from the abdomen to the upper pole; 25 mL is injected into the upper pole. Which of the following is the most appropriate Current Procedural Terminology (CPT) code?
CPT Code Description
11954 subcutaneous injection of filling material (e.g., collagen) over 10.0 mL
15877 suction-assisted lipectomy; trunk
19380 revision of reconstructed breast
20926 tissue grafts, other (e.g., paratenon, fat, dermis)
A) 15877 and 11954
B) 15877 and 19380
C) 19380
D) 20926
E) 20926 and 19380
The correct response is Option D.
Similar to skin grafting, fat grafting involves a donor site as well as graft and recipient preparation. Fat is harvested, and donor site is closed and dressed. Fat graft is processed and injected into the recipient site. Fat grafting is reported with code 20926 (tissue grafts, other [e.g., paratenon, fat, dermis]) and includes the following:
Harvest of the fat graft material by any method (e.g., syringe, suction- assisted lipectomy, incision)
Closure of the donor site, if indicated, with appropriate dressing
Processing of fat graft material
Injection of fat graft into recipient site
Dressing of recipient site
90 days of routine postoperative care
Code 20926 is not anatomical site-specific, nor is it volume dependent. Thus, both the injection of 50 mL of fat into the cheek concavity and injection of 500 mL of fat into the thigh for correction of contour irregularities are coded as 20926. This code is used for each anatomical area injected; thus, if both breasts had fat grafting, the Current Procedural Terminology (CPT) codes would be 20926 and 20926-59, because the second breast is recognized as a separate and distinct procedure.
Code 15877 (suction-assisted lipectomy; trunk) is not coded separately because harvest of the graft by any method is included in 20926.
Subcutaneous injection codes (11950–11954) describe the injection of “off the shelf” products such as collagen. These do not involve the harvest of tissue, and hence neither donor site nor postoperative care is involved.
Code 19830 (revision of reconstructed breast) may be appropriate if a large area or multiple areas of a reconstructed breast are grafted, because it may be better described as a “revision of the reconstructed breast.” Currently, however, there is no uniform established minimum volume to be considered sufficient to warrant use of code 19830 instead of 20926. Preauthorization for insurance reimbursement should be done for all fat grafting procedures, because not all payers will cover them, since there is no “functional improvement.”
A 25-year-old man is evaluated after sustaining a left zygomaticomaxillary complex (ZMC) fracture. On exploration of the fracture through the upper buccal sulcus, left brow, and left trans-conjunctival incisions, the fracture crosses the infraorbital foramen, and the left orbital floor fracture is significantly depressed and displaced. Open reduction and internal fixation (ORIF) of the orbital floor and ZMC fractures is performed. Which of the following is the most appropriate CPT code for this patient?
CPT CODE Description
21360 ORIF malar fracture only
21365 ORIF of “complicated” malar fracture only
21390 orbital blowout fracture repair, periorbital approach with alloplastic or other implant
A) 21360
B) 21365
C) 21390
D) 21360 and 21390
E) 21365 and 21390
The correct response is Option E.
21365 is the appropriate code for the zygomaticomaxillary complex (ZMC) fracture repair since the repair requires multiple incisions and the fracture crosses the infraorbital foramen. The orbital floor repair is not considered “bundled” with the repair of the ZMC fracture and should be billed separately as a distinct procedure.
21360 is not the appropriate code for this complicated ZMC fracture. 21390 is correctly added to this code, however.
21360 is the appropriate code for a simple repair of a ZMC fracture and does not include reduction and repair of the concurrent orbital floor fracture.
21390 is not the appropriate code without 21365.
21365 is the appropriate code for the ZMC fracture repair, however, this option omits the code for the reduction and repair of the orbital floor fracture.
A 35-year-old man is evaluated for a history of sleep apnea and nasal airway obstruction. Physical examination shows a narrowed middle vault with an internal valve of less than 10 degrees and a septum that deviates along the maxillary crest to the left, narrowing the airway. The operative plan is for spreader grafts from the septum, and submucous resection of the deviated portion of the septum. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for this procedure?
CPT CODE Description
20912 Septal cartilage graft
30410 Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip
30420 Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip, including major septal repair
30465 Repair of nasal vestibular stenosis
30520 Septoplasty or submucous resection with or without cartilage scoring, contouring, or replacement with graft
A) 20912 and 30420
B) 20912 and 30465
C) 30410 and 30465
D) 30420 and 30465
E) 30465 and 30520
The correct response is Option E.
In this patient, the most appropriate code is one that addresses the vestibular stenosis only: 30465. The more inclusive codes of 30410 and 30420 include surgery involving the lower lateral (alar) cartilages to address tip issues, and, in the case of 30410 and 30420, work on the bony pyramid as well; none of which are a component of the procedure undertaken, which is limited to addressing the internal nasal valve narrowing.
CPT code 30520 is most appropriate to use for the septoplasty because the harvesting of cartilage is included in the submucous resection surgical field, and, as a result, cannot be coded separately as a septal cartilage graft harvest. If one were not performing a septoplasty, then the most appropriate code would be 20912 for the septal graft harvest to be used for the spreader grafts.
A 67-year-old woman comes to the office because of a 1-year history of a 2-cm basal cell carcinoma of the cheek. The lesion is excised with a 5-mm margin leaving a 3.0 × 3.0-cm defect. The wound is closed with a rhomboid flap. Which of the following is the most appropriate current procedural terminology (CPT) code for this procedure?
CPT code Description
11100 biopsy of skin (including simple closure); single lesion
11643 excision, malignant lesion including margins face, 2.1 to 3.0 cm diameter
13132 repair, complex, cheek 2.6 to 7.5 cm
14040 adjacent tissue transfer or rearrangement cheeks defect 10 cm2 or less
14041 adjacent tissue transfer or rearrangement cheeks defect 10.1 cm2 to 30.0 cm2
A) 11100
B) 11643
C) 14041
D) 11643 and 13132
E) 14040 and 11643
The correct response is Option C.
The most appropriate current procedural terminology (CPT) code for this procedure is 14041, adjacent tissue transfer or rearrangement of cheek defect. In this case, the rhomboid flap is most accurately considered an adjacent tissue transfer. 11643, excision of a malignant lesion is not separately reportable with codes 14000-14302, and separate reporting would be considered unbundling.
If the lesion were excised and closed by wide undermining, only 11643 and 13132, complex closure and excision of malignant lesion, would be used. In this case, the closure consisted of more than simple undermining and thereby closure with an advancement flap is a more appropriate choice. Excision of benign or malignant lesion, excisional preparation of a wound bed, or debridement of an open fracture or open dislocation are not included in complex repair codes.
The choices of 11643 (excision of malignant lesion) or 11100 (biopsy of skin) both under-code based on the extent of the procedure in the described scenario.
A 45-year-old man is referred for scalp reconstruction after undergoing Mohs micrographic surgery for removal of squamous cell carcinoma of the scalp. The defect measures 5 × 10 cm. The scalp is reconstructed with a rotation flap measuring 20 × 30 cm with a 5 × 2-cm split-thickness skin graft on the secondary donor defect. When assigning a current procedural terminology (CPT) code for the adjacent tissue transfer, which of the following is the correct area to use?
A) 50 cm2
B) 600 cm2
C) 650 cm2
D) 810 cm2
E) 1000 cm2
The correct response is Option C.
Adjacent tissue transfer is one of the most common procedures performed by plastic surgeons, and accurate coding is essential for accurate reimbursement, insurance integrity, and ethical reasons.
The most appropriate method for calculating the area is to add the area of the defect to the area of the flap. The area of the defect is considered the “primary defect,” and the flap alone is considered the “secondary defect.” It is the combination of these that determines the area on which the current procedural terminology (CPT) codes are based. In this case the defect measures 5 × 10 cm, or 50 cm2. The flap itself measures 20 × 30 cm, or 600 cm2. Therefore, the total area used to assign the correct CPT code is 650 cm2.
The skin graft is over part of the secondary defect, which is already covered by the secondary defect measurement. However, the skin graft is an additional code that should be added to the codes for adjacent tissue transfer.
