Anesthesia
For Medicare purposes, just one anesthesia code is usually reported unless the second and subsequent anesthesia codes are...
add-on
For Medicare purposes, just one anesthesia code is usually reported unless the second and subsequent anesthesia codes are add-on codes.
Bilateral anterior ethmoidectomy via intranasal approach.
31200-50
For code 31200 50, go to CPT index main term Ethmoidectomy and subterm Anterior. Verify the code in the Excision subcategory of the Accessory Sinuses category in the Respiratory System subsection of the Surgery section. According to Optum's EncoderPro.com Expert, modifier 50 (Bilateral procedure) is added to the code.
Patient underwent aortic valve replacement with stentless tissue valve, by division. Cardiopulmonary bypass was provided.
33410
For code 33410, go to CPT index main term Aortic Valve Replacement, subterm Open, and qualifier with Stentless Tissue Valve. Verify the code in the Aortic Valve heading of the Cardiac Valves subcategory in the Heart and Pericardium category of the Cardiovascular System subsection in the Surgery section. Notice that "cardiopulmonary bypass" is included in the code description.
The physician determines the location of a thyroid cyst, using palpation, and aspirates it.
60300
For code 60300, go to CPT index main term Aspiration, subterm Cyst, and qualifier Thyroid. Verify the code in the Removal subcategory of the Thyroid Gland category in the Endocrine System subsection of the Surgery section. According to Optum's EncoderPro.com Expert, a directional modifier is not added to the code.
When multiple procedures and/or services are performed on the same date, report a(n)... code for each procedure and/or service documented.
Separate
When multiple procedures and/or services are performed on the same date, report a separate code for each procedure and/or service documented.
When procedures on the larynx and trachea are performed on a patient who is younger than one year of age, report code 00326, but do not report qualifying circumstances code... (anesthesia for patient of extreme age, younger than one year and older than 70) on the same claim.
99100
When procedures on the larynx and trachea are performed on a patient who is younger than one year of age, report code 00326, but do not report qualifying circumstances code 99100 on the same claim because the anesthesia services code description includes "children younger than 1 year of age."
Bilateral endoscopic treatment of a nosebleed.
31238-50
For code 31238 50, go to CPT index main term Hemorrhage, subterm Endoscopic Control, and qualifier Nose. Verify the code in the Endoscopy subcategory of the Accessory Sinuses category in the Respiratory System subsection of the Surgery section. According to Optum's EncoderPro.com Expert, modifier 50 (Bilateral procedure) is added to the code.
A seven-year-old child underwent repair of pulmonary atresia with ventricular septal defect by constructing a conduit from the left ventricle to the pulmonary artery.
33920
For code 33920, go to CPT index main term Repair and subterm Pulmonary Artery. Review codes in the Pulmonary Artery subcategory of the Heart and Pericardium category in the Cardiovascular System subsection of the Surgery section and select the appropriate code. The procedure statement documents "repair of pulmonary atresia with ventricular septal defect, and a prosthetic conduit was used," which provides guidance for code assignment.
The physician performed a total thyroid lobectomy on the right and a contralateral subtotal lobectomy on the left, including isthmusectomy.
60225
For code 60225, go to CPT index main term Lobectomy, subterm Thyroid Gland, and qualifier Total. Review codes in the Excision subcategory of the Thyroid Gland category in the Endocrine System subsection of the Surgery section, and select the appropriate code. The procedure statement documents "a total thyroid lobectomy on the right and a contralateral subtotal lobectomy on the left, including isthmusectomy," which provides guidance for code assignment.
Note: The total thyroid lobectomy was performed on the right and a contralateral subtotal lobectomy was performed on the left, including isthmusectomy. Code 60225 is assigned because it states, "Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy." According to Optum's EncoderPro.com Expert, a directional modifier is not added to the code.
Instructional... appear throughout the Medicine section to provide coding clarification and direction.
Notes
Instructional notes appear throughout the Medicine section to provide coding clarification and direction.
When anesthesia services are provided by an anesthesiologist to a breast cancer patient who undergoes a procedure that involves radical or modified radical breast procedure with internal mammary node dissection, assign code... AA P5.
00406
When anesthesia services are provided by an anesthesiologist to a breast cancer patient who undergoes a procedure that involves radical or modified radical breast procedure with internal mammary node dissection, assign code 00406 AA P5. To locate code 00406, go to CPT index main term Anesthesia and subterm Breast.
Endoscopic anterior and posterior (total) ethmoidectomy, left, with left maxillary antrostomy.
31255-LT and 31256-51-LT
For codes 31255 LT, go to CPT index main term Ethmoidectomy and subterm Endoscopic. Review codes in the Endoscopy subcategory of the Accessory Sinuses category in the Respiratory System subsection of the Surgery section and select the appropriate code. The procedure statement documents "endoscopic anterior and posterior (total) ethmoidectomy," which provides guidance for code assignment. According to Optum's EncoderPro.com Expert, modifier LT (Left side) is added to the code. The parenthetical note located below the code description indicates a group of CPT codes that cannot be reported in conjunction with 31255; the left maxillary antrostomy code is not included within that group of codes and is reported separately as an additional procedure code.
For code 31256 51 LT, go to CPT index main term Antrostomy, subterm Sinus, and qualifier Maxillary. Review codes in the Endoscopy subcategory of the Accessory Sinuses category in the Respiratory System subsection of the Surgery section and select the appropriate code. The procedure statement documents "endoscopic left maxillary antrostomy," which provides guidance for code assignment. Add modifier 51 (Multiple Procedures) to indicate that the procedure was performed during the same session as the primary procedure. According to Optum's EncoderPro.com Expert, modifier LT is added to the code. Modifier LT is an informational modifier, so it is reported second.
Patient underwent subtotal pericardiectomy, with cardiopulmonary bypass.
33031
For code 33031, go to CPT index main term Pericardiectomy and subterm Subtotal. Review codes in the Pericardium subcategory of the Heart and Pericardium category in the Cardiovascular System subsection of the Surgery section and select the appropriate code. The procedure statement documents a "subtotal pericardiectomy, with cardiopulmonary bypass," which provides guidance for code assignment. Do not assign a separate code for cardiopulmonary bypass because it is included in the procedure's code description.
The physician removed remaining thyroid tissue on one side, following an earlier partial thyroidectomy.
60260-50
For code 60260 50, go to CPT index main term Thyroidectomy and subterm Secondary. Verify the code in the Excision subcategory of the Thyroid Gland category in the Endocrine System subsection of the Surgery section. Add modifier 50 (Bilateral procedure) to the code per CPT's parenthetical note below the code description.
Add-on codes are reported for procedures and services performed in addition to a primary procedure, and they are identified in CPT with a(n)... symbol.
Plus(+)
Add-on codes are reported for procedures and services performed in addition to a primary procedure, and they are identified in CPT with a plus (+) symbol.
When monitored anesthesia care (MAC) is provided by the anesthesiologist or qualified nonphysician anesthetist instead of local anesthesia due to the patient's age or mental status, add HCPCS Level II modifier...
-QS
When monitored anesthesia care (MAC) is provided by the anesthesiologist or qualified nonphysician anesthetist instead of local anesthesia due to the patient's age or mental status, add HCPCS Level II modifier -QS (or QS) (Monitored anesthesia care).
Nasal endoscopy with biopsy, left.
31237-LT
For code 31237 LT, go to CPT index main term Biopsy, subterm Nose, and qualifier Endoscopic. Verify the code in the Endoscopy subcategory of the Accessory Sinuses category in the Respiratory System subsection of the Surgery section. According to Optum's EncoderPro.com Expert, modifier LT (Left side) is added to the code.
Subcutaneous cardiac rhythm monitor was inserted, including programming, in a 54-year-old patient.
33285
For code 33285, go to CPT index main term Insertion and subterm Subcutaneous Cardiac Rhythm Monitor System. Verify the code in the Subcutaneous Cardiac Rhythm Monitor subcategory of the Heart and Pericardium category in the Cardiovascular System subsection of the Surgery section.
Patient underwent percutaneous core needle biopsy of the thyroid gland.
60100
For code 60100, go to CPT index main term Biopsy, subterm Core Needle, and qualifier Thyroid. Verify the code in the Excision subcategory of the Thyroid Gland category in the Endocrine System subsection of the Surgery section. According to Optum's EncoderPro.com Expert, a directional modifier is not added to the code.
Immune Globulins, Serum or Recombinant Products: Intramuscular injection, rabies immune globulin (RIg), human.
96372 and 90375
For code 96372, go to CPT index main term Injection and subterm Intramuscular. Verify the code in the Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration) category of the Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration subsection in the Medicine section.
For code 90375, go to CPT index main term Rabies Immune Globulin (RIg) and subterm Human. Verify the code in the Immune Globulins, Serum or Recombinant Products subsection of the Medicine section. According to Optum's EncoderPro.com Expert, modifier 51 (Multiple procedures) is not added to the code.
Note: According to notes below the Immune Globulins, Serum or Recombinant Products subsection, these codes are reported in addition to injection administration codes as, for example, 96372, 90375.
When anesthesia services are provided for non-invasive imaging or radiation therapy, such as may be required for a patient with an intellectual disability, report code...
01922
For code 01922 23, go to CPT index main term Anesthesia and subterms Radiological Procedures and Non-Invasive Imaging. Review codes in the Radiological Procedures subsection of the Anesthesia section to select an appropriate code for anesthesia for non-invasive imaging or radiation therapy. Modifier -23 (Unusual anesthesia) is added to the code to indicate that anesthesia services were provided for a procedure that usually requires either no anesthesia or local anesthesia or because unusual circumstances indicate that the procedure must be performed under general anesthesia (instead of local or regional anesthesia).
Endoscopic frontal nasal exploration with removal of tissue from left frontal sinus and diagnostic endoscopy of left turbinates.
31276-LT
For code 31276 LT, go to CPT index main term Nasal Sinuses, subterm Endoscopy, and qualifier Exploration. Verify the code in the Endoscopy subcategory of the Accessory Sinuses category in the Respiratory System subsection of the Surgery section. Add modifier LT (Left side) to the code because its description is "Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed," and is considered a singular, unilateral procedure.
Patient underwent sinus of Valsalva fistula repair, with cardiopulmonary bypass.
33702
For code 33702, go to CPT index main term Repair, subterm Heart, and qualifier Sinus of Valsalva. Review codes in the Sinus of Valsalva subcategory of the Heart and Pericardium category in the Cardiovascular System subsection of the Surgery section and select the appropriate code. The procedure statement documents "sinus of Valsalva repair, with cardiopulmonary bypass." Do not assign a separate code for cardiopulmonary bypass because it is included in the procedure's code description.
Patient underwent incision and drainage of an infected thyroglossal duct cyst of the neck, which was the result of incomplete closure of the embryonic thyroglossal duct between the thyroid gland and the back of the tongue.
60000
For code 60000, go to CPT index main term Incision and Drainage, subterm Cyst, and qualifier Thyroid Gland. Verify the code in the Incision subcategory of the Thyroid Gland category in the Endocrine System subsection of the Surgery section. According to Optum's EncoderPro.com Expert, a directional modifier is not added to the code.
Biofeedback: Biofeedback training for anxiety using EMG and EEG modalities.
90901
For code 90901, go to CPT index main term Training and subterm Biofeedback. Review codes in the Biofeedback subsection of the Medicine section and select the appropriate code. The procedure statement documents "biofeedback training… using EMG and EEG modalities." (Report the code even though two modalities were used. EMG is the abbreviation for Electromyography, and EEG is the abbreviation for Electroencephalography.)