How Do You Bill for H&P?

Question:

The hospital requires our surgeons to perform and document an H & P prior to the patient having an elective gall bladder surgery. Sometimes it’s done in the office before the surgery and sometimes it’s done on the same day as the procedure. If this H & P is documented, can the E/M be billed? And does it make a difference if it’s done a week before the surgery?

Answer:

A pre-operative H & P, regardless of when it occurs, is included in the global surgical package and is not separately billable. CPT clarified this in 2009 in a CPT Assistant comment, see below:

“If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.” (Source CPT May 2009)

*This response is based on the best information available as of 8/14/25.

Intraoperative Nerve Stimulation

Question:

We are having difficulty locating a code. One of our hand surgeons is performing therapeutic nerve stimulation intraoperatively for regeneration of nerve. Is this reportable, and if yes, what is the code?

Answer:

Great question and thank you for asking us!

Two new Category III CPT codes have been introduced: 0882T and 0883T. These codes became effective on July 1, 2024, and are included in the 2025 CPT manual.

• 0882T – Intraoperative therapeutic electrical stimulation of a peripheral nerve to promote nerve regeneration, including lead placement and removal, upper extremity, minimum of 10 minutes; initial nerve

• 0883T – Intraoperative therapeutic electrical stimulation of a peripheral nerve to promote nerve regeneration, including lead placement and removal, upper extremity, minimum of 10 minutes; each additional nerve

Key points to note about these Category III codes:

• They are specific to the upper extremity

• Require a minimum of 10 minutes of stimulation

• Are add-on codes and must be reported in conjunction with a primary procedure

*This response is based on the best information available as of 8/14/25.

63081 or Something Else?

Question:

I received feedback from an external review and am now confused. A partial cervical corpectomy (30%) was documented and reported with CPT 63081, along with fusion and instrumentation. I’ve been informed that this is not a corpectomy. I'm looking for confirmation that this is correct feedback.

Answer:

Thank you for asking KZA!

CPT defines the minimum amount of bone removed for partial corpectomies—the minimum amount for the cervical spine is at least one-half (50%).

The feedback received is correct, as the documented 30% does not support reporting a partial corpectomy. Instead, this is appropriately reported as an ACDF, CPT 22551.

*This response is based on the best information available as of 8/14/25.

I&D for Cutaneous Abscess

Question:

I am new to Dermatology coding and need help with this procedure note: An I&D was performed on the left hand for a cutaneous abscess. Consent was obtained and risks were reviewed including but not limited to delayed wound healing, infection, need for multiple I and D's, and pain. The area was prepped in the usual clean fashion. Local anesthesia was achieved with 2 cc of 1% carbocaine. The abscess was incised with a 15 blade, and pressure was applied to the wound to drain the underlying contents. Aquaphor and a dry sterile dressing were applied and wound care was reviewed. Can you tell me what CPT code I should use?

Answer:

Welcome to Dermatology coding! We are happy to help you. In this note, the physician is performing an incision and drainage. The physician incised the abscess and drained the abscess. Typically, a simple I&D involves a single lesion or abscess just below the skin’s surface. The correct CPT code to report is 10060 (incision and drainage of abscess) and the diagnosis code is L02.512 (Cutaneous abscess of left hand).

*This response is based on the best information available as of 7/31/25.

Hernia Repair and Small Bowel Resection

Question:

A patient with open repair of an incarcerated hernia is noted to have necrotic bowel within the incarcerated hernia. This area of non-viable small bowel is resected and anastomosis is performed. Is this separately billable?

Answer:

Yes, if another organ is involved in the incarcerated hernia, and needs to be resected or repaired, this may be maybe separately reported with the appropriate hernia repair.

*This response is based on the best information available as of 7/31/25.

DRIL Procedure

Question:

The surgeon said he did a DRIL procedure on an AC fistula. I’m not sure how to code this. Is it an unlisted code?

Answer:

The DRIL procedure (Distal Revascularization with Interval Ligation) is a surgical intervention to treat complications related to hemodialysis access. It is performed to address complications arising from hemodialysis access, such as ischemia (reduced blood flow) or steal syndrome (where blood flow is diverted away from the limb) in the affected extremity. It involves restoring blood flow to a limb while also addressing issues like high flow or steal syndrome by ligating (tying off) a portion of the access. This procedure aims to reduce pain, improve tissue viability, and prevent further complications in the affected limb. This procedure has an existing CPT code and is reported as 36838. 

*This response is based on the best information available as of 7/31/25.