This month’s coding column addresses coding questions that have been submitted by AAOS members.
Using modifier 58 in staged procedures
Q: Our surgeon recently operated on a patient who had a traumatic injury to the lower extremity. The patient underwent initial excisional débridement at the first encounter on May 1, 2012. On May 3, 2012, the patient was returned to the operating room (OR) for a subsequent excisional débridement. Four days later, on May 7, 2012, it was obvious that the patient required a below-the-knee amputation. Is it appropriate to report both the second débridement and the amputation with modifier 58?
A: Based on the information you have provided, it appears that the second and third procedures are related to the plan of care for the management of the initial injury. As such, it is appropriate to append modifier 58 on the appropriate surgical CPT codes for the second excisional débridement (May, 3, 2012) and the third procedure, in this case, the amputation (May 7, 2012).
In-office PRP injections
Q: Our surgeon is administering platelet-rich plasma (PRP) injections in the office. Is it appropriate to bill the insurance company using CPT code 76942 (ultrasonic guidance) and CPT code 20551 for the injection, or must we report using the 0232T code?
A: The appropriate CPT code to report the PRP injection in the office setting is the Category III code, 0232T —Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed. Assuming the documentation supports the work associated with this code, 0232T should be reported to the insurance company and is also the correct code to report the service if the patient is self pay.
Do not separately report the injection code, the blood draw, the image guidance, or a code for the work associated with the spinning of the plasma. All work associated with this procedure in the office is inclusive to 0232T.
Q: Staff are drawing the blood and processing the PRP sample for the surgeon to administer. We have been advised that the surgeon may then report the injection code (eg, 20551) and the image guidance (eg, 76942 for ultrasonic guidance or 77002 for fluoroscopic guidance) because the surgeon did not perform the blood draw. Is this correct advice?
A: The correct code to report the PRP injection in the office is 0232T. The staff are performing the blood draw and preparation work under the direct supervision of the physician (Incident-To), thus it is incorrect for the surgeon to “unbundle” and report components of the code.
In-office hyaluronan injections
Q: Our surgeon administered a series of three hyaluronan injections to a patient in the office. The sole purpose of the patient’s visit each time was for the injection. As part of an internal, prospective, prepayment review, this was coded with CPT 20610 for the injection and the appropriate J-code for the drug. The surgeon, however, wanted evaluation and management (E&M) services billed at each visit because he said he evaluated the patient. Would that be appropriate?
A: No. If the documented E&M note was related to the knee and no other anatomic areas were evaluated or no significant changes in the knee requiring an E&M were found, E&M should not be billed. The hyaluronan injections were planned and the intent of the visits was for the injections. Therefore, the E&M is not a significant separate service and is not reportable in addition to the injection and drug codes.
Medicare also agrees with the CPT rules related to E&M services and hyaluronan injections. One local carrier has posted the following information on this topic:
“5. Evaluation and management service:
a. An E&M service may be appropriate if the decision to start the series of injections is made after an evaluation during the same visit. Indicate this by using an E&M code with modifier 25.
b. After the first injection, during the visits for subsequent injections, an E&M service will not be covered unless there was a separately identifiable problem for which the E&M service was required and rendered.”
Q: Our follow-up question relates to the “separate service” requirement. During the patient’s second visit, he was seen by the physician assistant (PA), who performed and documented the E&M service before the surgeon saw the patient and administered the second injection. The only E&M documentation is related to the knee and states that the patient is here for the second injection in the series. The surgeon wants the PA to report the E&M using modifier 25 and he wants to report the injection on a separate claim form. Does this scenario meet the “separate service” requirements?
A: Although the way the claim is submitted may make this appear to be two separate services, the significant separate rule does not apply. The PA is an extender to the physician, and although efficiencies may have been achieved in this visit, the services reportable—based on the medical necessity of the visit— are covered by CPT code 20610 and the appropriate HCPCS J-code for the drug administered.
Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.