Correct Current Procedural Terminology (CPT)* coding is a key area for surgical practice improvement. This column identifies several frequently asked questions and the correct coding for new technology and surgical techniques that have resulted in coding confusion.
A 60-year-old male was diagnosed with colon cancer and possible metastases found on preoperative imaging. At the time of colon resection, the surgeon performs an intra-abdominal diagnostic intraoperative ultrasound to assess the extent of the disease and impact on the surgical strategy. How is the intra-abdominal diagnostic ultrasound reported?
The intraoperative diagnostic ultrasound procedure is reported with either CPT code 76700, Ultrasound, abdominal, real time with image documentation; complete, or code 76705, limited (eg, single organ, quadrant, follow-up). A diagnostic intra-abdominal ultrasound is a valuable tool to assess the extent of disease. This assessment may include examining the liver, other organs, and/or mesentery. Based on the results of the diagnostic intra-abdominal ultrasound, the surgeon may either perform the planned procedure, modify the operation, or discontinue it. Findings of the ultrasound should be described in a separate portion of the operative report and images should be saved in the electronic health record or placed in the patient’s chart.
Can I report code 47563, Laparoscopy, surgical; cholecystectomy with cholangiography, when indocyanine green (ICG) dye is injected into a patient in the preoperative holding area and then minimally invasive fluorescent imaging is used to view structures during dissection?
No. It would be incorrect to report code 47563 for this clinical scenario. Instead, report code 47562, Laparoscopy, surgical; cholecystectomy. Although evaluation using fluorescent imaging may help to visualize structures, it does not confidently demonstrate choledocholithiasis, show the intrahepatic branches, or detect drainage into the duodenum like a traditional cholangiogram. It also does not include the additional work inherent to code 47563, including placement of a cholangiocatheter, injection of radiographic contrast material while viewing the imaging monitor, or reviewing plain films placed under the patient and exposed.
Many years ago, a patient with differentiated thyroid cancer had a partial right thyroid lobectomy and partial left thyroid lobectomy. It is now necessary to remove all remaining thyroid tissue on both sides. How is this reported?
Report code 60260, Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid, and append modifier 50, Bilateral procedure. When a surgeon removes only a portion of a right or left thyroid lobe and then needs to later remove the rest of that right or left thyroid lobe, it is a “completion thyroidectomy.” The end result is the complete removal of a right or a left thyroid lobe, not the complete removal of the total thyroid—both the right and left lobes.
What is the correct reporting of 90 minutes of total critical care services on a given calendar day by a single physician?
The answer depends on the payer. The CPT guidelines state that code 99292 is used to report additional block(s) of time of up to 30 minutes each beyond the first 74 minutes. Therefore, for private payers that follow CPT guidelines, you may report both code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes, and add-on code 99292, each additional 30 minutes, for a total of 90 minutes of critical care services.
However, on March 9, CMS implemented a new Medicare policy that requires a full 30 minutes be spent above the maximum time of 74 minutes in code 99291 before add-on code 99292 may be reported. Therefore, for Medicare patients (and payers that follow Medicare rules), a total of 90 minutes of critical care services would be reported only with code 99291. The add-on code 99292 may not be reported until at least 104 minutes (74 + 30) of critical care services has been provided.
Learn more
The American College of Surgeons, as a part of its ongoing endeavor to support Fellows, has partnered with KarenZupko & Associates (KZA) to provide virtual and on-demand courses about coding for evaluation and management services, surgical procedures, and trauma/critical care services. Physicians can receive AMA PRA Category 1 Credits™ for each course. For more information about the 2022 ACS General Surgery coding courses, visit the KZA website at karenzupko.com/general-surgery.
*All specific references to CPT codes and descriptions are © 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Dr. Samuel Smith is a pediatric surgeon, Little Rock, AR. He is a member of the ACS General Surgery Coding and Reimbursement Committee, and ACS advisor to the American Medical Association CPT Editorial Panel.
