Yes, CPT coding is an intricate and very specific procedure. Failing to select the right five-digit code that accurately describes a service or procedure your physician performed gets you a one-way ticket to Denied Claimsville. How do your coders reconcile differences between physician's notes and terminology used in CPT code descriptions? For more than 15 years, the American Medical Association, which owns and maintains the CPT (Current Procedural Terminology) codes, has published guidelines in its CPT Assistant newsletters that do just that. But if your coders aren't seeing and correctly applying guidelines such as these we've assembled below, they're costing your facility money. OSM

PROCEDURE: Multiple Trunk Liposuction Sites[1]
WHAT TO DO: Do...Report code 15877 (trunk suction-assisted lipectomy) for each area of liposuction on the trunk. Append modifier -59 to the subsequent procedures performed.
WHAT NOT TO DO: Don't...Undercode 15877 when multiple trunk sites were liposuctioned.

PROCEDURE: Deep Subcutaneous Lesion Excision[2]
WHAT TO DO: Do...Use an excision code from the Integumentary System (for example, 11400 ??" 11446, excision, benign lesion) when a lipoma is present in a superficial location. However, when the lipoma is in a deep subcutaneous, subfascial or submuscular location, report an appropriate code from the musculoskeletal system (for example, 21930, excision, tumor, soft tissue of back or flank) to describe more closely the work entailed. You'll need to consult the procedure report to determine the physician work involved in removing the lipoma.
WHAT NOT TO DO: Don't...Assign 11400??"11646 skin lesion codes when the lesion was excised from deep subcutaneous tissue or even deeper sites.

PROCEDURE: "Requiring Anesthesia/Under Anesthesia"[3]
WHAT TO DO: Do...Keep in mind that the CPT code descriptors that include the phrase "requiring anesthesia" or "under anesthesia" indicate that the work involved in that specific procedure requires the use of general anesthesia. Don't report code 23700 (shoulder manipulation under anesthesia) if general anesthesia is not provided.
WHAT NOT TO DO: Don't...Assign a CPT code that states "requiring anesthesia" or "under anesthesia" when local anesthesia or conscious sedation was used.

PROCEDURE: Bone Marrow Spinal Grafting[4]
WHAT TO DO: Do...Use code 38220 (bone marrow; aspiration only) to report the separate aspiration procedure if bone marrow is aspirated for grafting in an arthrodesis procedure. However, when the bone marrow is obtained before the arthrodesis, include the placement of the bone marrow aspirate as part of the arthrodesis procedure — don't report it separately.
WHAT NOT TO DO: Don't...Omit code 38220 when the bone marrow is aspirated intraoperatively during the spinal arthrodesis surgery.

PROCEDURE: Spermatic Cord Lipoma Excision During Hernia Repair[5]
WHAT TO DO: Do...Append modifier -59 (distinct procedural service) to code 55520 to indicate that excision of the spermatic cord lesion is a separate, distinct procedure from the inguinal hernia repair performed at the same surgical session.
WHAT NOT TO DO: Don't...Omit code 55520-59 when a spermatic cord is excised during inguinal herniorrhaphy.

PROCEDURE: Tonsillar Electrocautery and Adenoid Suction Diathermy/Ablation[6]
WHAT TO DO: Do...Assign tonsillectomy and adenoidectomy code 42820 or 42821 as appropriate for suction diathermy, a term generally applied to electrosurgery/electrocautery; medical diathermy generally indicates that no tissue harm or destruction is done; ablation implies removal or destruction of tissue. Whether performed with electrosurgical dissection, tonsillotome, cold knife dissection, laser, microdebrider, harmonic scalpel or thermal welding technique — removal of tonsils is a tonsillectomy, and removal of adenoids is an adenoidectomy, no matter what the technique.
WHAT NOT TO DO: Don't...Assign an unlisted CPT code when a non-traditional technique is used for tonsillectomy with adenoidectomy.

PROCEDURE: Laparoscopic wedge liver biopsy[7]
WHAT TO DO: Do...Assign code 47379 (unlisted laparoscopic liver procedure).
WHAT NOT TO DO: Don't...Assign code 49329 (unlisted laparoscopy procedure, abdomen, peritoneum and omentum).

PROCEDURE: Colonoscopy with Hot Biopsy Forceps Specimen[8]
WHAT TO DO: Do...Assign code 45384 (colonoscopy with removal of lesion by hot biopsy forceps or bipolar cautery) if a physician performs a colonoscopy and biopsies a polyp with the hot biopsy forceps (without entirely removing the polyp).
WHAT NOT TO DO: Don't...Assign colonoscopy with biopsy code 45380 when hot biopsy forceps are used to obtain a specimen.

PROCEDURE: GI Endoscopy with Injection[9, 10]
WHAT TO DO: Do...Report a code from the gastrointestinal endoscopy section, which contains codes for directed submucosal injection(s) of any substance [for example, 45381, colonoscopy, with directed submucosal injection(s), any substance]. Examples of substances that may be injected include: india ink, which marks a lesion so you can easily identify the involved segment of the gastrointestinal tract in the future. Other examples of submucosal injected substances are: botulinum toxin, saline and corticosteroid solutions. Also report a submucosal injection code when a polyp is injected with saline or "lifted" before removal by another technique (such as snare removal).
WHAT NOT TO DO: Don't...Omit the endoscopy with submucosal injection code.

PROCEDURE: Laparoscopic Mesh Placement[11]
WHAT TO DO: Do...Report a laparoscopic incisional hernia repair with implantation of mesh with unlisted laparoscopic hernia repair code 49569.
WHAT NOT TO DO: Don't...Assign open mesh implant code 49568 (implantation of mesh or other prosthesis for incisional or ventral hernia repair) when the mesh was implanted laparoscopically.

PROCEDURE: Cystoscopy with Multiple Bladder Tumors[12]
WHAT TO DO: Do...Rather than adding the tumor sizes together for a cumulative total size, measure each tumor individually to determine the appropriate category (small, medium, large) when multiple bladder tumors are fulgurated or resected using a cystourethroscope. Use code 52234 once for single or multiple tumors that individually measure 0.5 - 2.0 cm. Report code 52235 once for medium (single or multiple) tumors that individually measure 2.0 - 5.0 cm. Consider tumors larger than 5.0 cm to be large and report them once using code 52240.
WHAT NOT TO DO: Don't...Let physicians get away with not specifying in the operative reports the dimension of each bladder tumor when they remove multiple bladder tumors. Without this level of detail, coders routinely default to a single CPT code, when multiple codes may be justified.

PROCEDURE: Laparoscopic Lysis of Adhesions[13]
WHAT TO DO: Do...Report a laparoscopic lysis code (44180, 58660) if the following are documented in the medical record: Adhesions are multiple or dense, they cover the primary operative site or the lysis adds considerable time to the operative procedure and increases the risk to the patient.
WHAT NOT TO DO: Don't...Assign code 58660 or 44180 when the documentation doesn't support the separate reporting of the adhesiolysis.

PROCEDURE: Cystoscopy with Transvaginal Tape Surgery[14, 15]
WHAT TO DO: Do...Report code 52000 in addition to code 57287 (removal or revision of sling for stress incontinence), because code 57287 doesn't include the work of performing a cystoscopy. Don't report code 52000 (cystourethroscopy), in addition to code 57288 (sling operation for stress incontinence), when a cystoscopy is performed to confirm that the sling procedure was successful.
WHAT NOT TO DO: Don't...Assign code 52000 with code 57288, when the cystoscopy is performed to confirm the success of the sling procedure.

PROCEDURE: Bilateral Laparoscopic Oophorectomy/Salpingectomy[16]
WHAT TO DO: Do...Append modifier -50 to code 58661 (laparoscopy with removal of adnexal structures), which describes a unilateral procedure, to indicate the procedure was performed bilaterally if a laparoscopy and bilateral removal of ovaries and/or fallopian tubes are performed.
WHAT NOT TO DO: Don't...Omit the bilateral modifier -50 when bilateral laparoscopic removal of the ovaries and/or fallopian tubes is performed.

PROCEDURE: Multiple Spinal Electrodes[17]
WHAT TO DO: Do...Keep in mind that the CPT coding system makes no distinction as to the number of sites required for the placement of electrode catheters. CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) can be reported twice when two neurostimulator electrode catheters are placed through two separate sites.
WHAT NOT TO DO: Don't...Let physicians get away with not specifying in the operative report whether two separate sites were used to place two spinal electrodes. Without this level of detail, coders routinely default to a single CPT code, when multiple codes may be justified.

PROCEDURE: Epidurography[18]
WHAT TO DO: Do...Use code 72275 (epidurography, radiological supervision and interpretation) only when an epidurogram is performed, images are documented and a formal radiologic report is issued.
WHAT NOT TO DO: Don't...Code and bill code 72275 when no images and formal radiological report are on file.

PROCEDURE: Epidural Catheter Placement with Continuous Infusion[19]
WHAT TO DO: Do...Use codes 62318 and 62319 (injection, including catheter placement, continuous infusion or intermittent bolus, epidural or subarachnoid) when multiple (three or more) injections are given through a catheter that is placed in the subarachnoid or epidural space over a period of hours or one to two days. These multiple injections often involve different substances, such as placebo injection or varying amounts of narcotic, as part of a detailed diagnostic or treatment regimen.
WHAT NOT TO DO: Don't...Assign code 62318 or 62319 when a catheter was temporally used to perform a single epidural injection, and the catheter is then removed during the same operative session. Code such single injections as 62310 or 62311 [injection, single (not via indwelling catheter)] as appropriate.

PROCEDURE: Medial Branch Nerve Injections[20]
WHAT TO DO: Do...Remember that the facet joint injection codes are 64470 ??" 64476 (injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve). These codes refer to the injection of a facet joint either by:
? injection into the joint with one needle puncture, or by
? anesthetizing the two medial branch nerves that supply each joint (two needle punctures).

Do...Report the facet injection codes once when the injection procedure is performed irrespective of whether a single or multiple puncture is required to anesthetize the target joint at a given level and side. For example, injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint would be coded as 64475. Even though two separate injections are performed, the result is still a single facet joint block.

Do...Remember that the facet joint injection codes are 64470 ??" 64476 (injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve). These codes refer to the injection of a facet joint either by:
? injection into the joint with one needle puncture, or by
? anesthetizing the two medial branch nerves that supply each joint (two needle punctures).

Do...Report the facet injection codes once when the injection procedure is performed irrespective of whether a single or multiple puncture is required to anesthetize the target joint at a given level and side. For example, injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint would be coded as 64475. Even though two separate injections are performed, the result is still a single facet joint block.
WHAT NOT TO DO: Don't...Assign a facet injection code for each medial branch nerve that is injected/anesthetized, instead of reporting one code for the single facet joint that the two branch nerves supply.

PROCEDURE: Hook Dilation/ Stretching of Iris[21]
WHAT TO DO: Do...Keep in mind that cataract extraction in glaucoma patients can require complex techniques or maneuvers to accomplish cataract extraction and/or IOL insertion. For example, chronic administration of pupillary constriction medication (miotics) for glaucoma often reduces the pupillary response to mydriatics (drugs that cause pupillary dilation) administered before the extraction procedure. However, the dilation of the iris by manually stretching it with a hook inserted through the same incision doesn't justify the use of code 66982 (extracapsular cataract removal with insertion of intraocular lens prosthesis, complex).
WHAT NOT TO DO: Don't...Assign complex cataract extraction code 66982 when a hook is used to dilate/stretch the iris to alleviate papillary constriction.

PROCEDURE: Impacted Cerumen[22]
WHAT TO DO: Do...Know that the American Academy of Otolaryngology- Head and Neck Surgery (AAO-HNS) says that any of these must be present to consider the cerumen to be impacted:
? Visual considerations. Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane or middle ear condition.
? Qualitative considerations. Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching and hearing loss.
? Inflammatory considerations. Associated with foul odor, infection or dermatitis.
? Quantitative considerations. Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.

Removing wax that's not impacted doesn't warrant reporting CPT code 69210 [removal impacted cerumen (separate procedure), one or both ears]. Capture such work by an evaluation and management (E/M) code regardless of how it's removed.
WHAT NOT TO DO: Don't...Assign code 69210 when the documentation doesn't support the AAO-HNS- and AMA-approved "impacted" cerumen definition.

References:
1. Feb. 2005 CPT Assistant
2. Aug. 2006 CPT Assistant
3. April 2005 CPT Assistant
4. June 2007 CPT Assistant
5. July 2000 CPT Assistant
6. May 2008 CPT Assistant
7. Aug. 2006, Dec. 2007 CPT Assistant
8. Dec. 2005 CPT Assistant "Special Q&A Issue"
9. CPT Changes 2003: An Insider's View
10. Jan. 2004 CPT Assistant
11. Sept. 2001 CPT Assistant
12. Oct. 2002 CPT Assistant
13. Jan. 1996 CPT Assistant
14 Oct. 2000 CPT Assistant
15. Nov. 2007 CPT Assistant
16. Jan. 2002 CPT Assistant
17. March 1999 CPT Assistant
18. Parenthetical note under code 72275 in CPT code book
19. Jan. 2000 CPT Assistant
20. May 2004, Sept. 2004 CPT Assistant
21. Nov. 2003 CPT Assistant
22. July 2005 CPT Assistant