Billing for a Repair immediately Following Mohs Surgery

Question:

Can we bill for a simple repair when the surgeon performs Mohs?

Answer:

An intermediate or complex repair, flaps or grafts may be reported in addition to MMS.  The simple repair is included in the procedure and is NOT reported.

*This response is based on the best information available as of 05/11/23.

Mohs Surgery Question

Question:

We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation.

Answer:

The procedure note for Mohs Surgery should always contain

1. Indication for procedure
2. Biopsy results
3. Location of lesion
4. Number of lesion(s)
5. Size of the lesion(s),
6. Number of stages performed
7. Number of specimens per stage
8. Type of closure

In addition, the first stage must describe the histology of the specimens taken including:
Depth of invasion

1. Pathological pattern
2. Cell morphology
3. Perineural invasion/presence of scar tissue (if applicable)

*This response is based on the best information available as of 04/13/23.

Skin Cancer Screening

Question:

What is the correct CPT code or CPT code range for skin screening exam for lesions suspicious of skin cancer?

Answer:

It would NOT be appropriate for a dermatologist to report a code from the Preventive Medicine range (CPT 99381-99397) because a dermatologist is a specialist. If a patient comes in for a “routine” skin check, this should be coded with a problem-oriented E/M code (99202-99215). Also keep in mind most payors only cover a preventive visit one time per calendar year which is typically performed by the patient’s primary care practitioner.

*This response is based on the best information available as of 03/16/23.

What does “Separate Procedure “mean in a CPT Code Description?

Question:

What does “separate procedure” mean when it follows a CPT code description?

Answer:

Per CPT :Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

However, when a procedure or service that is designated as a “separate procedure” is carried out independently or considered to be unrelated or distinct from other procedures, report the code in addition to other procedures/services by appending modifier 59 to the specific “separate procedure” code. This indicates that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).

What does this mean in practice? If a code description includes the term “separate procedure”, if that procedure is in the same anatomic area as a more comprehensive procedure (for example, lyse of adhesions followed by a colectomy) only the more comprehensive procedure, the colectomy, is reported.

*This response is based on the best information available as of 02/16/23.

Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

*This response is based on the best information available as of 01/19/23.

Consultation Coding in 2023

Question:

In 2023, will the level of service be determined by history, exam and medical decision making, or will this change?  I have heard it is changing.

Answer:

Beginning January 1, 2023, consultation codes 99242-99255) for both inpatient and outpatient services will be based on medical decision making or time.  However, keep in mind a clinically relevant history and clinical examination should also be documented.  Also, consultation codes 99241 and 99251 have been deleted.

*This response is based on the best information available as of 12/15/22.