Coding Category

Superficial or Deep? 20680 vs. 20670

Q: How do you decide which CPT® is more appropriate, 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) or 20670 Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure)? Our physician is reporting 20680 for removal of implants on toes, heel, and wrist. Would these be more appropriately reported as superficial removal?

A: The CPT® codebook provides some specific instructions for the proper application of 20680 (vs. 20670, or other codes). These include:

(To report removal of hardware from proximal radius, other than radial head prosthesis, use 20680) 

(To report removal of hardware from the distal humerus or proximal ulna, other than humeral and ulnar prosthesis, use 20680) 

(To report removal of hardware, other than humeral and/or glenoid prosthesis, use 20680)

Beyond these circumstances, you should report 20670 for superficial implant removal, such as when the physician makes a small incision and removes the implant by pulling or unscrewing it. The incision is closed using sutures and/or steri-strips, but no layered closure is involved. Such procedures may be performed in the physician office.

Note that 20670 is a designated separate procedure, and should be reported only if it is the only procedure performed at a particular anatomic area/operative site. If the physician performs the service with another procedure involving the same area, you may not separately bill 20670. If you have any doubt whether separate coding is allowed, check the National Correct Coding Initiative (NCCI) edits.

Deep implant removal procedures (20680) are usually performed in an ambulatory surgical center or other facility setting (i.e., not in the physician office). The physician must make a deep incision (typically below the level of muscle) overlying the site to visualize the implant, and may use instruments to remove the implant from the bone. The physician repairs the incision by layered closure.

Per the AMA’s CPT Assistant (June 2009) and AAOS (American Academy of Orthopedic Surgeons) guidelines, you should report a single unit of 20680 for a single fracture site or area of injury, even if multiple stab incisions where necessary to remove all of the hardware. For example, you would not report multiple units of 20680 when an intramedullary rod (IM rod) is removed. The IM rode cannot be removed via a single incision because there are locking screws on both ends of the rod; therefore, stab incisions are made at two sites to release the screws. But, because the IM is considered to be a single implant system for fixation of one fracture site, you may report 20680 only one time.

Reporting multiple units of 20680 is appropriate when fixation device(s) are removed from separate fractures at different anatomical sites, or for two fractures that are classified as noncontiguous on the same bone (e.g., proximal and distal fracture sites). For example, you may report 20680 and 20680-59 Separate procedure for a bimalleolar fracture if screw(s) are removed from the lateral malleolus (distal fibula), and a plate with screws are removed from the medial malleolus (tibia) through a separate incision.

April 24th, 2014

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4 Quick Tips for Debridement Coding

1. Codes describing excision debridements deeper than skin only are organized by depth:

  • subcutaneous tissue (includes epidermis and dermis, if performed) – 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less and 11045 … each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
  • muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed) – 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less and 11046 … each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
  • bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) – 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less and 11047 … each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

2. Complete documentation for excisional debridement requires five elements, including:

i. A description of the procedure as “excisional”

ii. A description of the instrument used to cut or excise the tissue (e.g., scissors, scalpel, curette)

iii. A description of the tissue removed (e.g., necrotic, devitalized or non-viable)

iv. The appearance and size of the wound (e.g., down to fresh bleeding tissue, 7 cm x 10 cm, etc.)

v. The depth of the debridement (e.g., to skin, fascia, subcutaneous tissue, muscle, or bone)

If any of these elements is missing, documentation does not meet the criteria for excisional debridement. Note that debridement of the skin that is preparatory to further surgery, such as reduction of fracture, should not be coded as a separate procedure.

3. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.

For example: Bone is debrided from a 4 sq cm heel ulcer and from a 10 sq cm ischial ulcer. This is reported with a single code, 11044. When subcutaneous tissue is debrided from a 16 s. cm dehisced abdominal wound and a 10 sq cm thigh wound, report 11042 for the first 20 sq cm and 11045 for the second 6 sq cm. If all four wounds were debrided on the same day, apply modifier 59 Distinct procedural service with either 11042 or 11044, as appropriate.

4. Non-excisional debridement (e.g., 97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session) is described as nonsurgical because it does not involve cutting away or excising devitalized tissue. Rather, it is removal of devitalized tissue, necrosis, and slough by other methods, including:

  • Scrubbing
  • Washing
  • Water scalpel (jet)
  • Irrigation (under pressure)

Examples of non-excisional debridement are pulsed lavage, mechanical lavage, mechanical irrigation, high-pressure irrigation, etc. For instance, Versajet™ debridement is considered to be nonsurgical, mechanical debridement because it does not involve cutting away or excising devitalized tissue. Likewise, the Arobella Qoustic Wound Therapy System™ uses an ultrasonic assisted curette to debride wounds mechanically.

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CMS Clarifies Home Health Face-to-face Documentation Requirements

Since Jan. 1, 2011 a certifying physician must document that he or she—or an qualified non- physician practitioner (NPP)—had a face-to-face encounter with the beneficiary prior to certifying a beneficiary’s eligibility for the home health benefit. The Centers for Medicare & Medicaid Services (CMS) has clarified this documentation requirement in a special edition of the MLN Matters newsletter. The clarification “is intended for physicians who refer patients to home health, order home health services, and/or certify patients’ eligibility for the Medicare home health benefit, home health agencies, and non-physician practitioners (NPPs).”

As a condition of payment, a face-to-face encounter must occur within 90 days prior to the start of home health care, or up to 30 days after the start of care. CMS reiterates that the encounter document must include an explanation of why the clinical findings support that the patient is homebound, and in need of either intermittent skilled nursing services or therapy services. The agency stresses that diagnoses alone do not support the need for skilled service; that standard language (e.g., “taxing effort” or a notation such as “gait abnormality”) alone do not support homebound status, and; that most insufficient documentation errors occur because “the face-to-face encounter document does not sufficiently describe how the clinical findings from the encounter support the beneficiary’s homebound status and the need for skilled services.”

Per CMS, the two elements of the required brief narrative for documenting the home health face-to-face encounter are:

1. Confined to the home – Describe why the patient is homebound. An individual shall be considered “confined to the home” (homebound) if both of the following two criteria are met:

A. The patient must either:

  • Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
  • Have a condition such that leaving his or her home is medically contraindicated.

B. There must exist:

  • A normal inability to leave home; and
  • Leaving home must require a considerable and taxing effort.

2. Need for Skilled Services - To qualify for home health services, the beneficiary must need intermittent skilled nursing services, physical therapy (PT), or speech language pathology (SLP) services. Describe what the RN, PT, or SLP and other services will be doing in the home. For example, “skilled nursing required to assess and manage new COPD regimen.”

  • Skilled nursing services must be reasonable and necessary for the treatment of the patient’s illness or injury. Skilled nursing services can be, but are not limited to:
    • Teaching/training
    • Observe/assess
    • Complex care plan management
    • Administration of certain medications
    • Tube feedings
    • Wound care, catheters and ostomy care
    • NG and Tracheostomy aspiration/care
    • Psychiatric evaluation and therapy
    • Rehabilitation nursing
  • PT, OT, SLP must be reasonable and necessary for the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury within the context of his or her unique medical condition.Assuming all other eligibility and coverage requirements have been met, one of the following three conditions must be met for therapy services to be covered:

1. The skills of a qualified therapist are needed to restore patient function.

2. The skills of a qualified therapist are needed to design or establish a maintenance program.

3. The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy.

The MLN Matters article also provides examples of proper documentation, relative to the type of encounter.

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New Medicare Coverage for Pacemakers Used to Treat Bradycardia

If your practice sees patients with documented nonreversible symptomatic bradycardia, you should know that the Centers for Medicare & Medicaid Services (CMS) recently established a national coverage determination (NCD) allowing payment for implanted permanent cardiac single- or dual-chamber pacemakers, used for the treatment of this disease.

Coverage is effective for claims with dates of service on or after Aug. 13, 2013. Note, however, that Medicare contractors have until July 7, 2014 to implement this NCD. Claims for implanted permanent cardiac pacemakers submitted before July 7 may be denied, and claims may need to be resubmitted.

Payment for implanted permanent cardiac pacemakers is contingent on documentation of nonreversible symptomatic bradycardia due to:

  1. Sinus node dysfunction
  2. Second- or third-degree atrioventricular block

Append modifier KX to the procedure code to indicate that documentation is on file verifying the patient has non-reversible symptomatic bradycardia (ICD-9: 427.89 Other specified cardiac dysrhythmias; ICD-10 Bradycardia, unspecified).

The telltale sign of bradycardia is a heart rate less than 60 beats per minute, which may cause one or more of the following symptoms:

  • Syncope (780.2)
  • Seizures (780.3)
  • Congestive heart failure (482.0)
  • Dizziness (780.4)
  • Confusion (298.2)

For proper code selection, documentation must indicate whether the right atrium or right ventricle was targeted (single-chamber pacemaker), or both (dual-chamber pacemaker).

CPT® codes:
33206         Insertion of new or replacement permanent pacemaker with transvenous electrode; atrial
33207                  ; ventricular
33208                  ; atrial and ventricular

Local anesthesia (CPT® 00530 Anesthesia for permanent transvenous pacemaker insertion) is generally used to perform the inpatient procedure.

For complete details, see Medicare NCD Manual, chapter 1, part 1, sec. 20.8.3.

Source: CMS transmittal 161, CR 8528, Feb. 6, 2013

April 4th, 2014


You Break It, You Buy It: Fact or Fiction?

Question: I have a provider who insists that the “you break it, you buy it” rule is a coding urban legend. Is this guideline supported by policy?

Answer: The “you break it, you buy it” rule states that a surgeon cannot separately report (and receive compensation for treating) a complication during surgery if the complication occurs as a result of the surgery itself. This is demonstrated in the following example: If a surgeon injects epinephrine to control bleeding during a polyp removal (e.g., 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique), control of bleeding is not separately reported because the hemorrhage is due to snare polypectomy.

The basis of the “you break it, you buy it” rule is found in the National Correct Coding Initiative Policy Manual for Medicare Services. Chapter 1.C.13 allows, “Treatment of complications of primary surgical procedures is separately reportable with some limitations” [emphasis added]. Those limitations, however, are considerable. Specifically:

 … treatment of a complication of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in the operating room during the procedure or (2) if it occurs postoperatively and does not require return to the operating room.

For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78 [Unplanned Return to the Operating/Procedure Room By the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period].

Additional restrictions are found throughout the NCCI Policy Manual. For example, chapter 1.R states, “Complications inherent in an invasive procedure occurring during the procedure are not separately reportable. For example, control of bleeding during an invasive procedure is considered part of the procedure and is not separately reportable.”

Chapter 5.E.3 further advises:

If an iatrogenic laceration of the spleen occurs during the course of another procedure, repair of the laceration with or without splenectomy is not separately reportable. Treatment of an iatrogenic complication of surgery such as a splenic laceration is not a separately reportable service. For example if an iatrogenic laceration of the spleen occurs during an enterectomy, colectomy, gastrectomy, pancreatectomy, or nephrectomy procedure, the physician should not separately report a splenectomy CPT code (e.g., 38100, 38101, 38120).

Finally, chapter 6.E.9 states:

If an iatrogenic laceration/perforation of the small or large intestine occurs during the course of another procedure, repair of the laceration/perforation is not separately reportable. Treatment of an iatrogenic complication of surgery such as an intestinal laceration/perforation is not a separately reportable service. For example CPT codes describing suture of the small intestine (CPT codes 44602, 44603) or suture of large intestine (CPT codes 44604, 44605) should not be reported for repair of an intestinal laceration/perforation during an enterectomy, colectomy, gastrectromy, pancreatectomy, hysterectomy, or oophorectomy procedure.

In a nutshell: If the complication arises from the surgery, and the primary surgeon is able to deal with it at the time of the initial surgery, policy allows very little room to report treatment for the complication. As stated above in chapter 1.C.13, however, you may report treatment that requires a return to the operating room. This is further confirmed in chapter 5.C.5, which states, “If bleeding occurs in the postoperative period and requires return to the operating room for treatment, a HCPCS/CPT code for control of the bleeding may be reported with modifier 78 indicating that the procedure was a complication of a prior procedure requiring treatment in the operating room.”


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