Actively Assisting PA

Question:

What are the documentation requirements for a teaching physician when both a resident surgeon and a PA first assist are present in the operating room? The PA is actively assisting, and both individuals are noted in the operative report.

Answer:

In a teaching facility, if a resident acts as assistant and if that resident is considered (by the teaching physician) to be qualified to assist in the case, no third provider will be reimbursed as an additional assistant. If, however, the teaching physician attests that no qualified resident was available to act as an assistant, a PA may be billed as assistant. The resident may still be present for teaching purposes and listed as participating in the case.

The definition of “qualified resident“ is case specific. It may be that a resident is not physically available or that the available resident is considered (by the teaching physician) to not be clinically qualified for the specific operative case. A teaching facility’s compliance department may have specific language for an attestation statement.

*This response is based on the best information available as of 12/18/25.

Lobectomy with Substernal Component

Question:

I have a coding question that I'm hoping you can help me out with. If a doctor removes only one lobe of the thyroid and also includes the substernal component, should 60271 or 60220-22 be used? Thank you!

Answer:

Unless a sternal split is performed, report 60220 for a thyroid lobectomy. Code 60271 request splitting the sternum. If documentation supports significant additional work, modifier 22 may be append to 60220.

*This response is based on the best information available as of 12/04/25.

CPT 44130 “Separate Procedure” Designation

Question:

CPT 48150 describes a pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy, and gastrojejunostomy, with pancreatojejunostomy. CPT 44130 describes an enteroenterostomy, an anastomosis of the intestine, with or without cutaneous enterostomy, and is designated by CPT as a “separate procedure.”

According to NCCI edits, there is a procedure-to-procedure (PTP) conflict between 44130 and 48150 when performed during the same encounter, which can be bypassed with modifier 59. If a provider routinely performs an enteroenterostomy in conjunction with the Whipple procedure to prevent future bile reflux—a common postoperative complication—is it appropriate to append modifier 59 to 44130?

Given that these procedures are frequently performed together, could the enteroenterostomy be considered an integral component of the Whipple procedure, rather than a distinct, independent, or unrelated service? While the Whipple procedure description does not specifically include an enteroenterostomy, it does involve bile redirection via choledochoenterostomy. The enteroenterostomy similarly aids in bile flow redirection, serving as an additional step to reduce bile reflux.

In light of this, should these procedures be routinely unbundled and billed together?

Answer:

While modifier 59 can technically be used to bypass the NCCI edit between CPT 44130 and CPT 48150, it is not generally appropriate to routinely unbundle and report these codes together.

According to Medicare NCCI guidelines and CPT principles regarding “separate procedures,” CPT 44130 should only be reported when it is performed independently or is clearly distinct from other procedures. In the context of a Whipple procedure (CPT 48150), the enteroenterostomy is typically considered an integral part of the overall surgical approach, especially when performed to prevent bile reflux—a known complication.

CPT 48150 is the Column 1 (comprehensive) code, and CPT 44130 is the Column 2 (component) code. The “separate procedure” designation for 44130 indicates that it should not be reported in conjunction with a more extensive procedure unless it is truly separate and unrelated.

Therefore, unless there is clear documentation that the enteroenterostomy was performed for a distinct reason unrelated to the Whipple procedure, routinely appending modifier 59 to report both codes together would not align with coding guidelines.

*This response is based on the best information available as of 11/20/25.

Does a Figure-Eight Suture Qualify as Intermediate Repair?

Question:

I was told a figure eight suture is considered intermediate closure. Is this correct?

Answer:

A figure-eight suture is just a closure technique, not a repair classification. The depth of the wound and layers repaired determine whether the closure is coded as simple, intermediate, or complex.

*This response is based on the best information available as of 11/06/25.

Coding for Traumatic Serosal Tear

Question:

How do you recommend coding for a traumatic transverse colon serosal tear? My coder used "repair of transverse colon." I am getting push back because I said it was a clean case (no spillage of GI contents and no contamination." I am told I can't use Clean classification because of how it was coded. Please advise!

Answer:

Serosal tears after trauma are not separately reported. They are included in the primary procedure. The colon was not lacerated/injured and was not repaired so colon repair may not be reported.

*This response is based on the best information available as of 10/23/25.

Pyogenic Granuloma

Question:

Hello! Could KZA clarify if the excision of a pyogenic granuloma (lobular capillary hemangioma) would be assigned to a code from the musculoskeletal or integumentary system? We have seen some conflicting information.  

Answer:

Thank you for reaching out to KZA!

The origin of the lesion will direct you to the appropriate code selection.

According to CPT:

• Lesions of cutaneous origin are appropriately reported with the excision of lesion integumentary codes (114xx & 116xx).

• Lesions of non-cutaneous origin are appropriately reported with the excision of tumor codes from the musculoskeletal section of CPT (2xxxx).

Pyogenic granulomas are benign, generally considered of cutaneous origin, and reported with a 114xx benign lesion code. If the documentation is unclear, it is best practice to query the surgeon for clarification.

*This response is based on the best information available as of 10/09/25.