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Clarification: Breast Revision Procedures 

Coding Clinic for HCPCS, Fourth Quarter 2022: Page 17       

Coding advice contained in this issue is effective with procedures/services provided after December 6, 2022, unless otherwise noted.       

The Central Office has received a request for clarification of the advice published in Coding Clinic for HCPCS Fourth Quarter 2020, Pages 1-3, on breast reconstruction when compared to the advice published in CPT Assistant September 2022 Pages 18-19. 

Coding advice for breast reconstructions has evolved since the publication of Coding Clinic for HCPCS Fourth Quarter 2020. In light of updated breast reconstruction guidance published in the September issue CPT Assistant, the previous Coding Clinic for HCPCS advice has changed.       

The coding updates are as follows:  

CPT code 19380, Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction), is appropriately assigned when documentation supports extensive breast capsule revision in addition to extensive soft-tissue revisions on the same breast. This includes when performed during a second stage breast reconstruction. CPT code 19342, Insertion or replacement of breast implant on separate day from mastectomy, is assigned in addition to code 19380 only when documentation supports there is extensive breast capsule revision, extensive soft-tissue revisions on the same breast and additional work necessary due to resizing of the breast implant (different size, different shape). CPT code 19342, may be reported in addition to CPT code 19370, ;Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy, only when provider documentation supports additional work was necessary due to resizing of the breast implant (different size, different shape) in addition to the extensive capsule revision. Replacement of an implant of the same size and shape (previous or new) is not reported separately from the primary procedure. This updated coding guidance supersedes the advice in Fourth Quarter 2020, Pages 1-3. Coding professionals should be guided by the most current coding advice.

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CPT: Coding Clarification: Removal of Orthopedic Fixation (Codes 20670 and 20680)

CPT Assistant June 2009, Volume 19, Issue 6, page 7

Removal of Hardware

When the fracture is stable or healed, all forces are borne by the bone. At this point, the external fixation is no longer needed and can be safely removed. Subsequent casting, bracing, or surgery may also follow the removal of external fixation. CPT codes 20690-20697 relate to the application, adjustment and removal, of an external fixation system. CPT code 20694, Removal, under anesthesia, of external fixation system, would be appropriately reported only when anesthesia is required to perform removal of the external fixator system. Removal of the external fixator performed without anesthesia is not a separately reportable procedure because local infiltration of medication(s), anesthetic or contrast agent before, during, or at the conclusion of the procedure is an inclusive service of codes 20670, 20680, and 20690.

Code 20680, Removal of implant; deep (eg, buried wire, pin, screw, metal band, rod or plate), describes a unit of service that is reported only once provided the original injury is located on one site, regardless of the number of screws, plates, rods or incisions. An example would be the removal of a single implant system, which may call for "stab" or multiple incisions (eg, intramedullary (IM) nail and several locking bolts). Multiple use of code 20680 would be appropriate only when the hardware removal was performed for another fracture in a different anatomical site unrelated to the first fracture (eg, ankle and humerus). In these circumstances, modifier 59, Distinct procedural service, would be appended to subsequent uses of the code. For example, two different and noncontiguous implants are removed from two different bones or two different (noncontiguous) sites on the same bone using multiple incisions. Depending on whether the implants were superficial or deep, code 20680 may be reported twice or codes 20680 and 20670, Removal of implant; superficial (eg, buried wire, pin, or rod (separate procedure), may each be reported. If there was an extraordinary amount of work, or unusual effort involved in the removal (eg, bone buried screws or an exceptional scar), then modifier 22, Increased procedural services, may be appended to the code for the procedure and submitted with the usual accompanying documentation.

Examples of Use of Codes 20670 and 20680 To assist coders in discerning whether to use code 20670 or 20680, the following examples discuss a single implant, single and multiple fracture treatment, and specific products. Removal of Deep or Superficial Bimalleolar Plate and Screws Code 20680 would be used to describe the removal of a plate (eg, periarticular plate, locking plate, or one-third tubular plate) and screws from the fibula in a healed bimalleolar ankle fracture. If deep buried medial malleolar screws are removed from the tibia's medial malleolus at the same session, use code 20680. If removing superficial screws from the fibular fracture, code 20670 should be reported. If superficial screws are removed from the tibia's medial malleolus at the same session, the procedure is reported using code 20670 with modifier 59 appended. Removal of Plate and IM Nail and Interlocking Screws - Proximal Tibial Plateau and Tibial Shaft Fractures (Noncontiguous Fractures) During the same surgical session, if a plate and its associated screws are removed from a healed proximal tibial plateau fracture, and an IM nail with its interlocking screws are removed through a separate skin or fascial incision from a healed tibial shaft fracture where both implant systems were used in the same tibial bone for noncontiguous fractures, report code 20680 for one of the implant systems (eg, plate and screws) and code 20680 with modifier 59 appended for the other implant system removal (eg, IM nail and screws). Recognize that the plate and all of its associated screws can be removed through one long extensile incision, or the plate and some screws may be removed through a smaller, less-invasive incision, with the remaining screws being removed through smaller stab incisions. In either instance, code 20680 should be reported only once for the plate and screw system removal. Also recognize that IM nail systems (ie, nail and interlocking screws) cannot be removed through one extensile incision, but are routinely removed through a larger incision for IM nail removal and one or more smaller incisions for removal of one or more interlocking screws. Therefore, code 20680 should be reported only once for the removal of the IM nail and any or all of the interlocking screws when performed on the same day by the same physician. Removal of Separate Plate/Screw Systems - Both Bone Forearm Fracture Code 20680 is reported once for each bone when removing internal fixation of healing fractures of "both bones" (radius and ulna) of the forearm when each bone is treated with separate plates and screws. If the plate and screw system is removed from the ulna at the same session as the radius, code 20680 with modifier 59 appended is reported. These plates may be described by size (eg, small fragment system or small fragment plate) or by a trademark or type (eg, locking plate, periarticular plate, or polyaxial locking plate). Alternatively, the hardware may be described by the name of the manufacturer. Each plate and screw system removal procedure would be reported separately using code 20680 with modifier 59 appended to denote distinct procedural services (eg, different site or separate incision) performed on the same day by the same physician. Removal of any and all screws used for each fixation system (ie, one plate and its associated screws) is part of the service of the plate removal.

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Removal of Buried Screw

Coding Clinic for HCPCS, Fourth Quarter 2004 Page: 9

Question 3: We are concerned with the overuse of modifier 59. Some of our coders feel that modifier 59 should not be reported unless you get a CCI edit and others contend that whenever modifier 59 is warranted, even if it is obvious that the two procedures are separate, you would append modifier 59. When reporting the removal of a buried screw in two different areas, (arm and leg), would it be appropriate to report CPT code 20680 twice with a modifier 59?

Answer: It would be appropriate to report code 20680, Removal of implant; deep, twice for the removal of a buried screw in two different areas. Append modifier 59 to the second CPT code to identify that the two procedures are separate from each other. Modifier 59 should only be appended to the CPT code(s) when reporting multiple procedures that would normally be denied if billed together but due to particular circumstances the CPT code(s) are deemed appropriate.

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Exchange of Hardware

Coding Clinic for HCPCS, First Quarter 2010 Page: 6

Coding advice contained in this issue is effective with procedures/services provided after March 15, 2010 unless otherwise noted.

QUESTION #15 A patient who underwent an ankle fusion previously was seen at our facility with areas of localized tenderness of the medial ankle. Work-up revealed a prominent screw head as the cause of the localized tenderness. A decision was made to remove the screw and exchange it with a shorter screw. What are the appropriate code assignments for this scenario?

ANSWER Presently, there is no CPT code for exchange of hardware. Therefore, report CPT code 20680, Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate, for removal of the screw from the medial ankle. CPT code 27899, Unlisted procedure, leg or ankle, would be reported for the insertion of the shorter screw. HCPCS CODING CLINIC.

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Bone Grafting of Femur and Tibial Tunnels

Coding Clinic for HCPCS, Third Quarter 2020: Page 11       

Coding advice contained in this issue is effective with procedures/services provided after September 17, 2020, unless otherwise noted.  

Question 11 :A patient with a left knee anterior cruciate ligament tear, torn lateral meniscus and retained hardware from a previous anterior cruciate ligament reconstruction presented for a left knee arthroscopic anterior cruciate ligament repair, open removal of retained hardware and bone grafting of the distal femur and tibial tunnels.       

Following the arthroscopic anterior cruciate ligament repair, a tibial incision was made through subcutaneous tissue to access the tibial tunnel in order to remove the deep hardware. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. What code(s) would be reported for the open removal of retained deep hardware, along with placement of bone graft to the femur and tibial tunnels? Is it appropriate to assign codes for both the arthroscopic and open portions of the procedure?  

Answer : Assign CPT code 29888, Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction, for the arthroscopic left anterior cruciate ligament repair. Also assign CPT code(s) 20680, Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail rod or plate), for removal of the retained hardware and 27599, Unlisted procedure, femur or knee, for the bone grafting of the distal femur and tibial tunnels and append modifier LT, Left side, to identify the knee laterality. The removal of the hardware and the tunnels were performed as open procedures. Since the procedures occurred at different sites.

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Antibiotic Cement Spacer

Coding Clinic for HCPCS, Fourth Quarter 2020: Page 8       

Coding advice contained in this issue is effective with procedures/services provided after December 10, 2020, unless otherwise noted.  

Question 4 : A patient with failure of a previous rotator cuff repair presented with right infected proximal humerus osteomyelitis, retained foreign body, draining sinus and biceps tendinitis. Following irrigation and debridement of skin, muscle and bone associated with the draining sinus and osteomyelitis, a decision was made to remove the humeral head and replace it with an articulating antibiotic spacer. The spacer was cemented in place with a mix of gentamicin impregnated cement, vancomycin and tobramycin. In addition, when removing the humeral head, previously placed anchors were removed. Once everything was in place, a biceps tenodesis was performed. How is the use of the antibiotic cement captured? Is it appropriate to assign CPT code 11981?  

Answer : Assign CPT code 23470, Arthroplasty, glenohumeral joint; hemiarthroplasty, for the removal of the humeral head and placement of the antibiotic spacer. The biceps tenodesis is inherent and not separately reported, however, CPT code 20680, Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate), may be reported for the removal of the previously placed anchors.       It is not appropriate to assign CPT code 11981, Insertion, non-biodegradable drug delivery implant, for the antibiotic cement. A drug delivery implant was not inserted, and mixing antibiotic into the cement is not additionally reported.

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Surgery: Respiratory System, Lysis Laryngeal Stenosis with Laser

CPT Assistant, November 2012, Volume 22, Issue 11, page 14  

Question: The patient has tracheolaryngeal stenosis. The provider performs microlaryngoscopy with lysis of the stenosis using laser and excision of granulation followed by a steroid injection. How is this reported?  

Answer: There is no specific CPT code for lysis of laryngeal stenosis (with or without laser). Therefore, the removal of the stenosis would be reported using an unlisted code 31599, Unlisted procedure, larynx. Whether the steroid injection is into the site of granulation, the area of stenosis, or both, code 31571, Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope, would be reported, as this is distinctly separate work. It is suggested that the coder review the procedure report or consult the physician.

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Surgery: Respiratory System

CPT Assistant, March 2017, Volume 27, Issue 3, page 10  

Question: What is the appropriate code to report for shaving/reduction of a patient's thyroid notch or Adam's apple (chondrolaryngoplasty)?  

Answer: Currently, there is no specific CPT code to report for shaving/reduction/partial removal of a patient's thyroid notch or Adam's apple (chondrolaryngoplasty). Although the procedure is commonly referred to as a "tracheal shave" it is performed on the thyroid cartilage notch, a laryngeal structure. The procedure is not performed on the trachea. The laryngoplasty family of codes (31580-31592, including 31551-31554) was revised in 2017 and none of these describes this service. Code 31599, Unlisted procedure, larynx would be the appropriate code to report. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service.

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Surgery: Respiratory System

CPT Assistant, July 2022, Volume 32, Issue 7, page 18  

Question: What is the appropriate code to report a procedure in which the surgeon uses direct laryngoscopy and an operating microscope and/or telescope to incise the subglottic stenosis with a knife?  

Answer: There is no specific code to report incising or scoring the subglottic stenosis at one or more sites. Therefore, unlisted code 31599, Unlisted procedure, larynx, should be reported for this procedure. When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service

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CPT: Repair of Rotator Cuff

Coding Clinic for HCPCS, Fourth Quarter 2004 Page: 10

Question 7: This patient with a torn rotator cuff and labrum tear was seen at our facility for an arthroscopy of the right shoulder with debridement of the rotator cuff tear and labrum tear. He also underwent a subacromial decompression followed by an open rotator cuff repair. What are the appropriate code assignment(s) for the procedures performed?

Answer: Report code 23410, Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute, for the open rotator cuff repair. Code 29826, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release, for the arthroscopy with subacromial decompression procedure performed. Modifier 59 should be appended to the second code to bypass any edits. The debridement would be integral to the open procedure performed and is not coded.

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CPT: Arthroscopic Shoulder Surgery

Coding Clinic for HCPCS Third Quarter 2012 Page: 5

Coding advice contained in this issue is effective with procedures/services provided after November 15, 2012 unless otherwise noted.

QUESTION 3 A patient with left shoulder impingement symptoms dating back to a motorcycle accident was seen today to undergo a diagnostic left shoulder arthroscopy with arthroscopic subacromial decompression and debridement. According to the coding rationale for CPT code 29826, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie arch) release, when performed, this code cannot be reported alone. CPT coding guidelines specifically state that the surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy. How would the arthroscopic subacromial decompression with a diagnostic arthroscopy be appropriately reported? ANSWER 3 It would be appropriate to report CPT code 29822, Arthroscopy, shoulder, surgical; debridement, limited, and code 29826, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed, for the arthroscopic subacromial decompression performed. A subcromial decompression usually involves debridement of soft tissue and bone removal. If the debridement is not clearly documented the coder should query the physician for clarification.

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CPT: Arthroscopic Shoulder Surgery

Coding Clinic for HCPCS Fourth Quarter 2012 Page: 7

Coding advice contained in this issue is effective with procedures/services provided after February 15, 2013 unless otherwise noted.

Question 3: A patient has a long history of neck and shoulder pain and now presents to have arthroscopic shoulder surgery which includes decompression with acromioplasty, claviculectomy, extensive debridement, and synovectomy. A standard posterior portal was made and the scope was introduced into the glenohumeral joint where extensive synovitis was noticed. An anterior portal was made and complete synovectomy was performed in the rotator area and the posterior and inferior capsular margins. Extensive intra-articular debridement was performed for the degenerative labral tear. A complete bursectomy for extensive synovitis and bursitis in the subacromial space, accessed from the same standard posterior portal was performed, in addition to a subacromial decompression with acromioplasty. A coracoacromial ligament release and distal claviculectomy were performed along with additional debridement in the superior joint capsule. After complete irrigation all portals were closed and patient was in stable condition. We want to report CPT codes 29826, 29824, 29823, and 29821 for the procedures performed. However, codes 29823 (extensive debridement) and 29821 (complete synovectomy) trigger an edit. Can you please clarify whether codes 29823 and 29821 can or cannot be reported since they are considered inherent into code 29824 (claviculectomy)? Or would both procedures be considered performed at a "separate site" within the shoulder and reported with modifier 59 appended? Answer Assign CPT codes 29826, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release, and 29824, Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure), for the procedures performed. Different sites or separate compartments within the shoulder are not recognized in the NCCI edits. Therefore, CPT code 29823 is considered bundled with 29824 and would not be separately reported. Additionally, CPT code 29821, Arthroscopy, shoulder, surgical; synovectomy, complete, would not be reported nor would modifier 59, Distinct Procedural Service, be appended, because the synovectomy is considered bundled into the other procedures performed. The synovectomy was performed through the same portal and is considered a contiguous structure within the shoulder; therefore, not a separate and distinct site.


 

CPT: Surgery: Musculoskeletal System, Arthroscopic Decompression

CPT Assistant, September 2012, Volume 22, Issue 9, page 17  

Question: My physician performs an arthroscopic procedure for decompression, then performs an open procedure for rotator cuff repair (23412, Repair of ruptured musculotendinous cuff [eg, rotator cuff] open; chronic) and claviculectomy (23120, Claviculectomy; partial). However, code 29826, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure), is an add-on code. How do we report the procedure?  

Answer: In addition to codes 23412 and 23120, the arthroscopic decompression procedure should be reported as well. In this specific instance, it is appropriate to additionally report either code 29822, Arthroscopy, shoulder, surgical; debridement, limited, or code 29823, Arthroscopy, shoulder, surgical; debridement, extensive. Code 29822 or 29823 may be reported as appropriate, when a subacromial decompression is done by itself. For example, if a subacromial decompression is performed alone, which usually involves debridement of soft tissue and bone removal, code 29822 may be reported. If there is extensive work performed in the removal of the soft tissue and bone, report code 29823. Modifier 59 should be appended to either code 29822 or 29823 to indicate a separately distinct procedure has been performed.

 

CPT: CPT Assistant, August 2001, Volume 08, Issue 11, page 11

Musculoskeletal System, 23130, 23410 (Q&A)

Question When reporting an acute rotator cuff repair, should the partial acromionectomy be reported separately with code 23130, Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release?

AMA Comment From a coding perspective, code 23410, Repair of musculotendinous cuff (eg, rotator cuff); acute, includes the work involved in performing a partial acromionectomy. Therefore, it would not be appropriate to report 23130 separately.

 

CPT: Surgery: Musculoskeletal System

CPT Assistant, February 2015, Volume 25, Issue 2, page 10  

Question: Does code 23412, Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic, include a partial acromioplasty or acromionectomy with or without coracoacromial ligament release?   Answer: No. Code 23412 does not include a partial acromioplasty or acromionectomy with or without coracoacromial ligament release. To report such a procedure, use code 23130.
 

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Surgery: Female Genital System

CPT Assistant November 2007, Volume 17, Issue 11, pages 8-9

Question: The surgeon used an open approach to remove a sling for stress incontinence and used the cystoscope in the procedure. What are the appropriate codes to report?

Answer: It would be appropriate to report code 57287, Removal or revision of sling for stress incontinence (eg, fascia or synthetic), in addition to code 52000, Cystourethroscopy (separate procedure), because code 57287 does not include the work of performing a cystoscopy

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CPT Assistant, June 2003, Volume 06, Issue 13, pages 6-9

Description of Procedure: CPT Code 55866

The patient is taken to the operating room and placed in the modified lithotomy position. The lower abdomen is prepped and draped in the standard fashion. A pneumoperitoneum is achieved in the standard fashion and four trocars are placed. The laparoscope is introduced and attention is turned to first dissecting the seminal vesicles and vas deferens. The peritoneum at the reflection point of the anterior rectum and posterior bladder is incised. The vas deferens is identified on each side and then divided. The seminal vesicles are carefully dissected out using the harmonic scalpel to divide all bleeding vessels until the structures are freed completely. The space just posterior to the seminal vesicles is dissected in order to open Denonvilliers fascia, thereby revealing a pre-rectal fat plane. Attention is then turned to complete mobilization of the opening of the peritoneum and mobilization of the bladder. The median umbilical ligaments and urachus are divided close to the umbilicus. Careful blunt dissection is used to reflect the bladder away from the abdominal wall. This exposes the endo-pelvic fascia. The fat overlying the endo-pelvic fascia then is cleared off and the endo-fascia is incised bilaterally to free the prostate away from the lateral pelvic side wall. The dorsal vein complex is developed, and suture ligated with a 2-0 suture. The bladder neck is then opened. The catheter is removed, and a curved urethral sound is placed to aid in traction of the prostate. This allows identification of the posterior bladder neck, which then is carefully dissected away from the base of the prostate. The area of the pedicles of the prostate then is taken down. The tissue is opened overlying the seminal vesicles; these structures are then withdrawn into the area of dissection and used as traction. Both lateral pedicles then are taken down, up to the level near the apex. The dorsal vein complex is then divided. Careful sharp dissection is used around the apex of the prostate. The prostate is rocked back and forth, and dissection continues along the lateral pedicle plane to define the apex of the prostate posteriorly. The urethra then is identified, and sharp dissection is used to divide the anterior and posterior urethra and the rectourethralis muscle. Then the final attachments are undone, and the specimen is withdrawn in the endo-cath sac. Hemostasis is assured. The vesicourethral anastomosis is performed with interrupted 2-0 suture. A 20 catheter is placed through the anastomosis. A 19 drain is placed through one of the abdominal side ports. All of the four trocar sites are inspected, and all surgical sites inspected at 5mm Hg pressure before removing the trocars under direct vision.

CPT: Laparoscopic Simple Prostatectomy

CPT Assistant, December 2022, Volume 32, Issue 11, page 8

Clinical Example (55867): A 65-year-old male who is symptomatic due to obstruction from prostatic enlargement chooses to undergo laparoscopic simple suprapubic prostatectomy.  

Description of Procedure (55867)     

Make a suprapubic incision and introduce a needle. Confirm an intraperitoneal position and create a pneumoperitoneum. Place a midline trocar and insert a zero-degree lens camera. Inspect the abdomen and pelvis for visceral injury or abnormal anatomy. Make five additional incisions after appropriate measurements, and place five additional trocars under direct vision. Adjust the table to place the patient in a steep Trendelenburg position and advance the robot. The four robotic arms are individually docked and pressure points are checked. Make appropriate adjustments to the robotic arms at the surgical console. Next, introduce the laparoscope and mobilize the colon so it is away from the bladder. Make an incision in the posterior bladder wall. Place several stay sutures in the bladder wall to expose the base of the bladder. Identify the ureteral orifices and survey the prostate anatomy to assess for median lobe location and relational anatomy to the bladder. Make an incision at the junction of the prostate and the bladder neck. Carry the incision circumferentially along the capsule of the prostate out laterally and distally. Rock the prostate back and forth and continue dissection along the lateral pedicle plane to define the apex of the prostate posteriorly. Unfasten the final attachments and place the specimen into the endosac and place out of the surgical field. Decrease the pneumoperitoneum and inspect the entire surgical field for evidence of bleeding. Once hemostasis is obtained, advance the bladder neck to the urethral mucosa using fine monofilament suture. Hemostasis is also achieved using cautery and suture. Close the posterior bladder wall with suture. Pass a catheter into the bladder and test the closure by placing 200 ml of saline into the bladder to distend it. Place a drain through one of the abdominal side ports. Inspect all six trocar sites and all surgical sites at 5 mm Hg pressure before the trocars are removed under direct vision. Extract the specimen by enlarging the midline incision and transferring the endosac bag to this area, where it is removed. Close the rectus fascia using suture, inject local anesthetic into all five of the trocar incisions, and close the trocar incisions with interrupted 2-0 nylon sutures. Place sterile dressings over each incision and secure the catheter to the patient's thigh with a catheter strap.

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Surgery: Male Genital System CPT Assistant, March 2012, Volume 22, Issue 3, page 10  

Question:  Would you please provide coding clarification for the following scenario: The urologist performs a robotic prostatectomy for the treatment of prostate cancer, and during the same session also performs a laparoscopic robotic Marshall-Marchetti-Krantz (MMK) urethropexy procedure to prevent stress incontinence. How are these services reported?  

Answer: The robotic prostatectomy is reported with code 55866, Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed, and the laparoscopic robotic MMK urethropexy is reported separately with code 51990, Laparoscopy, surgical; urethral suspension for stress incontinence, or code 51992, Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic)

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Surgery/Integumentary System

CPT Assistant June 2008, Volume 18, Issue 6, pages 14 - 15

Question: If two lesions are removed but only one excision is made, how is this reported?

Answer: From a CPT coding perspective, it is appropriate to report only one excision of lesion code. For example, if two benign skin lesions, measuring 0.5 cm each, are removed with one excision, then only one excision of lesion code would be reported. Because only one excision was performed, it would not be appropriate to report two separate excision of lesion codes. The excision of lesion code should accurately reflect the maximum excised diameter of the two lesions that were excised. For example, two 0.5-cm facial lesions located 1 cm apart that are excised through a single excision would have a maximum excised diameter is 0.5 cm + 1.0 cm + 0.5 cm = 2 cm. Code 11442 would be reported.

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Then and Now: Reporting of Cutaneous Excision Pending Pathology

CPT Assistant, May 2012, Volume 22, Issue 5, page 13

Now ,In general, the selection of the appropriate excision code is determined by three parameters: location, maximum excised diameter (which includes the margin), and lesion type (ie, benign or malignant). When the lesion is clearly benign (eg, cyst, lipoma, prior biopsy of benign neoplasm), the excision can be coded as benign at the time of surgery (11400-11471). When there is a prior biopsy showing malignancy, the excision can be coded as malignant at the time of surgery (11600-11646).  

Coding excision of a cutaneous lesion pending pathology (eg, lesion of unspecified behavior) as malignant before pathology is available could result in incorrect coding if the lesion is found to be benign on histopathologic examination. Therefore, if the lesion is not clearly benign or malignant, coding and billing should be delayed until the pathology has been confirmed.

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​CPT: Surgery: Integumentary System, Extensive Undermining

CPT Assistant, November 2022, Volume 32, Issue 11, page 21  

Question: Following excision of a basal cell carcinoma on the arm, a 2.7-cm-wide surgical defect is closed with an intradermal purse-string suture. The defect is broadly undermined beyond the edges to mobilize tissue. How is this reported?  

Answer: Because extensive undermining beyond the defect edges is performed to mobilize the wound edges, both excision and a complex repair code would be appropriate to report. For this scenario, the malignant excision on the arm would be reported with code 11603, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm, and the complex repair would be reported with code 13121, Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm.

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CPT: Coding Clarification: Endoscopic Injection

CPT Assistant, June 2010, Volume 20, Issue 6, page 4

Control of Gastrointestinal Hemorrhage 

Reports may describe injection in conjunction with attempts to control spontaneous bleeding resulting from causes, such as diverticulosis, angiodysplasia, or prior session interventions. When injection therapy is used to control hemorrhage not associated with esophageal or gastric varices, the codes below are used, depending on the extent of the base endoscopic procedure. The codes to report the control of bleeding are used only once, even if the injection therapy is combined with other modalities to control hemorrhage.

For example, if the injection of epinephrine is combined with placement of a clip or use of a cautery probe, the control of bleeding code should only be used once. The control of bleeding related to an intervention in the same session (eg, polypectomy) is included in the intervention service.

Exception to Endoscopy Injection and Control of Bleeding Codes     

Bleeding that starts as a result of a therapeutic intervention (eg, snare removal or biopsy) and is controlled by any method, is considered part of the initial therapeutic procedure and, should not be separately reported with codes for injection and/or control of bleeding.

Exception to code 45335: For injection to control bleeding, report code 45334.     

Exception to code 45381: For injection to control bleeding, report code 45382.

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CPT:Surgery: Digestive System

CPT Assistant, January 2017, Volume 27, Issue 1, page 6  

Question: What is the appropriate CPT code to report a colonoscopy during which two flat polyps in the transverse colon were removed via a saline injection-lift technique using a hot snare? Is a colonoscopy with a polypectomy removed by injection of epinephrine for a lift polypectomy reported differently?

Answer: Submucosal injection of substances, whether saline or epinephrine, to lift the polyp and facilitate a polypectomy, is reported with code 45381, Colonoscopy, flexible; with directed submucosal injection(s), any substance. The polypectomy would be reported with code 45385, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, with modifier 59 appended.  

    Endoscopic mucosal resection (EMR [eg, code 45390 with colonoscopy]) includes cap-assisted or ligation-assisted (banding) removal of a lesion, along with injection-assisted snare removal techniques. Whether performed in the upper or lower gastrointestinal tract, EMR requires the lift technique to create a space beneath the lesion to isolate the lesion from underlying submucosa, and the use of a specialized device to isolate the tissue to be removed. Coding for EMR procedures requires the performance of

(1) a submucosal injection to lift the lesion;

(2) demarcation of the lesion, often by creating a pseudopolyp out of tissue; and

(3) endoscopic snare resection.

If all three components are not performed, it is not appropriate to report an EMR procedure; rather, the service(s) performed (submucosal injection [45381 only], snare polypectomy [45385 only] are separately reported.

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ICD Guideline

2) Chronic kidney disease and kidney transplant status       

Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient's stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.

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Integumentary vs Musculoskeletal Lesion Excisions

CPT Assistant, April 2010, Volume 20, Issue 4, page 3  

There is often confusion in determining whether the excision of soft tissue tumors is reported with codes from the integumentary system or the musculoskeletal system. To dispel this ambiguity, new codes and guidelines have been established for the integumentary and musculoskeletal system in the CPT 2010 codebook. This article will provide an overview on the different types of lesion excisions in the integumentary and musculoskeletal systems, as well as describe the additions and revisions to these codes and guidelines.  

Review of Skin Anatomy     

Skin, the body's largest organ system, includes the epidermis (thinner outer layer) and the dermis (thicker inner layer). Below the dermis is the subcutaneous tissue, then the fascia, which is the layer between the subcutaneous tissue and the underlying muscle.

Lesions deep to the skin may occur in the soft tissue, deep subcutaneous plane, subfascial (below the fascia), intramuscular (into the muscle), or submuscular (below the muscle).  

Integumentary System Guidelines     

Guidelines for the excision of integumentary lesions have been clarified in CPT 2010.       

Simple closures are included in the excision of benign and malignant skin lesions. If an intermediate closure (codes 12031-12057) or complex closure (codes 13100-13153) is required, it should be separately reported. When reconstructive closures are required, they are separately reported with codes 15002-15261 and 15570-15770.       

The following are the three repair (closure) definitions:  

1. Simple repair: used when the wound is superficial; eg, involving primarily epidermis, dermis, and subcutaneous tissue and no deeper structures. The wound closure involves closing one layer, and includes local anesthesia, and chemical or electrocauterization of unclosed wounds.

2. Intermediate repair: includes requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia. Single-layer closure of heavily contaminated wounds, which required extensive cleaning or removal of particulate matter also constitutes as intermediate repair.

3. Complex repair: requires more than layered closure, such as scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions.

Integumentary Lesion Excisions     

The Integumentary System guidelines listed in the CPT 2010 codebook define an excision as the removal of a lesion, including margins, through the full thickness of the dermis, and including simple (nonlayered) closure and local anesthesia.

Code selection is determined by measuring the greatest clinical diameter of the apparent lesion, plus the margin required for complete excision, prior to the procedure. Integumentary excision procedures may require simple, intermediate, or complex closures.

Simple repair is included in the lesion excision and is not reported separately. However, repair by intermediate or complex closures should be reported separately.

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For example, if a malignant skin lesion on the left arm measuring 1.0 cm is excised with 0.3-cm margins (excised diameter 1.6 cm), and requires a complex closure of the wound of 3.0-cm length after accounting for manipulation of the wound for closure, report CPT code 11602, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm, for the excision; for the repair, report code 13121, Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm.       

Note that when the excision of benign or malignant skin lesions (codes 11400-11446 and 11600-11646) is performed in conjunction with an adjacent tissue transfer (codes 14000-14302), only the adjacent tissue transfer should be reported, as the excision is included in this procedure.  

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New Musculoskeletal System Guidelines     

Whether reporting the excision or radical resection of soft tissue tumors from the subcutaneous, fascial or subfascial layer, appreciable vessel exploration and/or neuroplasty should be reported separately. Simple and intermediate repair closures are included in the excision procedures, but if complex repairs with extensive undermining or other techniques are performed to close a defect created by a lesion excision, the complex repair codes are reported -separately. The excision of musculoskeletal lesions (tumors), includes the dissection or elevation of tissue planes in order to allow resection of the tumor, and therefore, those services are not reported separately.

The code selection for musculoskeletal lesion excisions is determined by measuring the greatest diameter of the tumor, in addition to the narrowest margin required for the complete excision of the tumor, based on the physician's judgment, at the time of the excision.

The radical resection of soft tissue tumors may be confined to a specific layer, for instance the subcutaneous or subfascial tissue, or it may involve the removal of tissue from one or more layers. Radical resection of soft tissue tumors is most commonly used for malignant or very aggressive benign tumors.   

Musculoskeletal Lesion Excisions     

Musculoskeletal lesion excision codes pertain to subcutaneous, superficial, or deep soft tissues under the skin, which may include subcutaneous fat, fascia, muscle and bone. Soft tissue excision codes are dispersed throughout the CPT 2010 musculoskeletal section and are categorized by anatomic site.  

When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor. For example, in order to report code 26116, Excision, tumor, soft tissue, or vascular malformation, of hand or finger; subfascial (eg, intramuscular); less than 1.5 cm, the tumor must be down to the muscle (ie, located between the fascia and muscle) or be intramuscular, such as a muscle sarcoma.  

Coding Tip :For radical resection of tumors of cutaneous origin (eg, melanoma), report the appropriate code from the 11600-11646 series. Appropriate code choice is based on the measurement of the tumor plus its margin made at the time of excision. 

The physician must determine the depth of the excision in order to ascertain whether the integumentary system or musculoskeletal system CPT codes are appropriate. Documentation must reflect what is being performed, in order to substantiate the selection of these codes.  

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Coding Tip : For radical tumor resection, neuroplasty and reconstructive procedures (eg, adjacent tissue transfer, flap) should be reported in addition to the excision code.       

The following are the different types of excisions, as listed in the guidelines:  

Subcutaneous soft tissue tumors: involve the simple or marginal resection of tumors confined to subcutaneous fatty tissue below the skin, but above the deep fascia.

Fascial or subfascial soft tissue tumors: involve the resection of tumors confined to the tissue within or below the deep fascia, but not involving the muscle or bone. Included are digital (ie, fingers and toes) sub-fascial tumors that involve the tendons, tendon sheaths, or joints of the digit.

Radical resection of soft tissue tumors: involve the resection of a tumor, usually malignant, with wide -margins of normal tissue.

Radical resection of bone tumors: involve the resection of the tumor with wide margins of normal tissue. Radical resection of bone tumors is usually performed for malignant tumors or very aggressive tumors. (See CPT Assistant February 2010.)

Frequently Asked Questions

Question: A deep subcutaneous mass (ie, not subfascial) requiring a resection of less than 3-cm diameter in the posterior aspect of the left ankle is excised. Would the integumentary lesion excision code series 11400-11471 or 11600-11646 be reported?  

Answer: No. The 11400-11471 and 11600-11646 series of codes (benign and malignant integumentary lesion excisions) describe excisions of cutaneous lesions, as well as superficial subcutaneous lesions such as cysts and scars.        

When the lesions are located in deep subfascial or submuscular tissues, the appropriate code from the Musculoskeletal System should be reported to describe the procedure. Therefore, code 27618, Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm, should be reported for the excision of this deep subcutaneous mass in the posterior aspect of the left ankle.  

Question: May I report code 19260, Excision of chest wall tumor including ribs with Modifier 52 appended, if the excision of a 10-cm chest wall mass did not include removing the ribs?  

Answer: No. It would not be appropriate to report code 19260, Excision of chest wall tumor including ribs, with Modifier 52 appended, as the procedure did not involve removal of the ribs. If the procedure involves removing a chest wall tumor without the ribs, it would be more appropriate to report a musculoskeletal tumor excision code, such as code 21557, Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or anterior thorax; less than 5 cm, depending on the depth, size, and malignant or benign nature of the lesion.  

Question: What would be the appropriate CPT code for excision of a sebaceous cyst on the scalp or on the face that is subdermal or deeper?  

Answer: Integumentary lesion excision codes pertain to the epidermis, dermis, and subcutaneous tissue, while musculoskeletal lesion excision codes pertain to subcutaneous, superficial or deep soft tissues. Code ranges 11400-11446 and 11600-11646 represent lesions that normally occur on the surface of the skin (epidermis) or near the surface of the skin (dermis), compared to the type of lesion (or tumor) that occurs in the subfascial or fascial tissue, muscles and joints, as listed in the musculoskeletal section.

A sebaceous cyst is a skin lesion and may be very large, distending the skin and pushing into the subcutaneous fatty tissue, but it is a skin lesion, and therefore, should be coded using the integumentary lesion excision codes, depending on the size of the cyst.       

Code range 21011-21016 lists the excision codes for soft tissue tumors—subcutaneous and subfascial—on the face or scalp. When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor. The physician must determine and document the depth of the excision to determine whether the integumentary system or musculoskeletal system CPT codes are appropriate.  

Terms Defined

1. Subcutaneous soft tissue tumors: usually benign and resected without removing a significant amount of surrounding normal tissue.  

2. Fascial or subfascial soft tissue tumors: usually benign, involve fascia and/or muscle, and resected without removing a significant amount of surrounding normal tissue.  

3. Digital (ie, fingers and toes) subcutaneous tumors: adjacent to—but not breaching—the tendon, tendon sheath, or joint capsule.  

4. Digital (ie, fingers and toes) fascial or subfascial tumors: involve the tendon, tendon sheath, or joint capsule.  

5. Radical resection of soft tissue tumors: most commonly used for malignant tumors, and extremely aggressive -benign tumors in which wide margins of normal tissue are excised.

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Excision or Resection of Soft Tissue Tumors

Coding Clinic for HCPCS, Third Quarter 2018: Page 1             

Musculoskeletal System.       

Soft tissue tumors refer to a tumor located within the soft tissue. These tumors can occur almost anywhere including the soft tissue between the muscles, ligaments, nerves, and blood vessels. These tumors can be either malignant or benign. The code assignments for soft tissue excisions or resections are anatomic site specific and can be located under main term Tumor in the index of the CPT codebook. The depths of soft tissues are identified as follows:  

Subcutaneous soft connective tissue tumors — Tumors confined to subcutaneous tissue below the skin but above the deep fascia. Code selection is based on the location and size of the tumor.

Fascial or subfascial soft tissue tumors — Tumors confined to the tissue within or below the deep fascia, but not involving the bone. Code selection is based on the location and size of the tumor.     

Please note, detailed guidance providing descriptions defining the depth of soft tissue tumors can be found in the Musculoskeletal System section of the CPT codebook.

Simple and intermediate repairs following the excision or resection would be included in the code assignment for the excision or resection of the soft tissue tumor and not separately reported. Complex repairs, skin grafts, and flap grafts would be separately reported if a reconstruction is required.       Additionally, if surrounding soft tissue is removed during a radical resection of a bone tumor, the radical resection of soft tissue tumor codes would not be separately reported.Let's look at a few questions received in our office and the responses provided:  

QUESTION 1: Patient was prepped and dissection was carried through the hypodermis and the lipoma capsule was identified and dissected. The lipoma of the left upper back extended through the fascia and included a subfascial component. However, it did not involve the musculature. The skin was closed in layers; deep and superficial dermis.What is the appropriate CPT code for the excision of the lipoma?  

ANSWER: Based on the documentation submitted a 5cm incision was made along the skin tension lines along the left upper back. Using a fine clamp, the lipoma capsule was identified. The lipoma extended through the fascia and included a subfascial component but did not involve the musculature. Because the excision did include a subfascial component, it would be appropriate to report either CPT code 21932, Excision, tumor, soft tissue of back or flank, subfascial (e.g., intramuscular); less than 5 cm, or CPT code 21933, ;Excision, tumor, soft tissue of back or flank, subfascial (e.g., intramuscular); 5 cm or greater, dependant on the size of the lesion excised. The size of the tumor was not documented therefore a definitive code cannot be provided.  

QUESTION 2 : Patient presents for excision of an umbilical mass. Manual pressure was applied and a 13-14 mm verrucous mass was delivered from within the umbilicus. The mass was transected and additional tissue was debrided. The fascial defect and umbilical skin were all closed and repaired in order to create a natural appearing umbilicus. What is the correct CPT code for the procedure performed?  

ANSWER: Based on the documentation submitted, report CPT code 22902, Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm, for the excision of the umbilical mass.       According to the operative report submitted the base of the umbilicus was grasped where the granulation type tissue ended and the mass was transected sharply. The remaining umbilical skin was closed and tacked to the repaired fascia to create a natural appearing neo-umbilicus.  

QUESTION 3 :Patient with a ganglion cyst and an osteophyte on the interphalangeal (IP) joint of the right index finger presents for removal. A digital block administered and incision made over the distal phalanx creating skin flaps. The ganglion cyst was removed first.

Then another incision was made and carried to the joint surface and the distal interphalangeal (DIP) joint was entered while protecting the extensor tendon, the osteophytes were debrided and removed with a curette and rongeurs. The skin was closed. What are the correct codes for removal of the ganglion cyst and the osteophytes of the right index finger?  

ANSWER: It would be appropriate to assign CPT codes 26210, Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger, for the excision of the osteophyte from the distal interphalangeal joint (DIP) and 26160, Excision of lesion tendon sheath or joint capsule (e.g., cyst, mucous cyst, or ganglion), hand or finger, for the excision of the cyst from the radial border of the index finger.       

Reporting both CPT codes produces an NCCI edit. Although the removal of the cyst and osteophytes were removed from the same joint, a separate incision was made to accomplish the procedure.       Therefore, append modifier 59, Distinct Procedural Service, to identify that a separate incision was made in order to remove the cyst and/or the osteophytes and append modifier F6, Right hand, second digit, to identify the finger treated.

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CPT: Surgery: Female Genital System

CPT Assistant, December 2011, Volume 21, Issue 12, page 16  

Question: Is code 58660 to be used only for adhesiolysis of the ovaries and fallopian tubes or more broadly for pelvic adhesiolysis? For example, during a laparoscopic procedure, a surgeon performs extensive lysis of omental adhesions from the abdominal wall. Should code 58660 or code 49329 be reported?  

Answer: There is no specific CPT code for laparoscopic lysis of omental/abdominal adhesions. Because adhesions may complicate the successful performance of the laparoscopic procedure, lysis of adhesions is often the first step of the exploration and may not be coded separately. If the adhesions are extensive and take significant additional work, code 49329, Unlisted laparoscopy procedure, abdomen, peritoneum and omentum, may be reported in addition to the primary procedure. Documentation must reflect the additional work required for the removal (lysis) of dense adhesions.        

To differentiate—while code 58660, Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure), involves endoscopic inspection and evaluation of the abdomen and pelvis, it represents uterine adnexal (ie, fallopian tubes, ovaries functionally and structurally adjacent to the uterus), adhesiolysis of any degree performed by any method. Code 58660 may be reported in addition to the primary procedure, only if dense/extensive adhesions are encountered that require effort beyond that which is ordinarily provided for the laparoscopic procedure. As code 58660 is designated as a separate procedure, modifier 59, Distinct Procedural Service, should be appended to indicate that code 58660 is not considered an integral component of the other procedure(s).

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CPT: Lysis of Adhesions

Coding Clinic for HCPCS Third Quarter 2010 Page: 5

Coding advice contained in this issue is effective with procedures/services provided after October 15, 2010 unless otherwise noted.

QUESTION #14 A patient with chronic pelvic pain and severe dyspareunia presents for laparoscopy. The patient was brought to the operating room and given general anesthesia. The laparoscopy was started and numerous adhesions were found between the omentum and uterus, as well as the omentum and anterior abdominal wall. These extensive adhesions were taken down with sharp and blunt dissection and a Ligasure device was also utilized to remove these adhesions. This portion of the procedure required significant operating time before the remainder of the operation was completed, which included right salpingo-oophorectomy, fulguration of pelvic endometriosis, and chromopertubation. Would it be appropriate in this scenario to separately report the lysis of adhesions?

ANSWER: Lysis of adhesions are typically included as part of the laparoscopic procedure. However, if dense and/or extensive adhesions are found that require effort beyond that require additional work outside of the procedure being performed, it would be appropriate to separately report the lysis of adhesions. Therefore, based on the operative report submitted, it would be appropriate to report CPT code 58660, Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure), in addition to CPT codes 58661, Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy), and 58662, Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method, for the procedures performed.

Modifier 59, Distinct Procedural Service, should be appended to CPT code 58660 to indicate that the procedure reported is separate and distinct from the main procedure being performed.

Please note, however, to separately report lysis of adhesions documentation must support that dense and/or extensive adhesions were encountered and that they required a significant amount of additional work to remove the adhesions.

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