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Question: We have a patient who comes in monthly for a tracheotomy tube change. Is it proper to code 31502 for this?

Arkansas Subscriber

Answer: Since code 31502 (Tracheotomy tube change prior to establishment of fistula tract) is assigned for a tube change before the point where sufficient healing forms the fistula tract which usually occurs within a few days of placement of the original tube it is probably not the best code for regular trach changes. For these visits, a relevant (and probably low-level) evaluation and management (E/M) code would be more appropriate.

Question: When coding for an outpatient clinic visit such as neurology for a patient receiving treatment for Parkinson's disease, our neurologist stated that the patient was also being treated for congestive heart failure, diabetes and osteoarthritis. Can I code these conditions also, even though the physician isn't directly treating the patient for them? I was told to do so.

California Subscriber

Answer: While it may be inappropriate to add codes for the congestive heart failure, diabetes and osteoarthritis in many situations, it is correct to code secondary diagnoses for the purpose of supporting medical decision-making or medical necessity. For pharmaceuticals or ancillary testing ordered during the course of the visit, insurers may require this supporting information.

Question: If the ED physician performs fracture treatment (whether it's closed treatment with a cast or reduction), should we code it as a facility even though the patient is going to an orthopedist for follow-up? My argument is that we should report closed treatment with or without reduction because we are not subject to global packaging (as the ED doctor is).

New Mexico Subscriber

Answer: You are correct if the physician performs invasive fracture treatment, you should report the appropriate fracture treatment code. However, if the patient is only splinted and instructed to follow up with a specialist for treatment, hold off on the fracture treatment code and report only the splinting code. The more invasive reduction or casting service will likely occur later.

Question: One of our surgical oncologists is doing a new procedure insertion of a MammoSite catheter into the breast to deliver brachytherapy at a later date. I can only come up with 19499 (Unlisted procedure, breast). Any other suggestions? The doctor insists it isn't a mammotomy.

Massachusetts Subscriber

Answer: Unfortunately, 19499 is actually your best choice for now, since there isn't yet a specific code to describe the MammoSite insertion. The catheter can be inserted at the time of lumpectomy or up to 10 weeks postsurgery under general or local anesthesia.

During the procedure, the catheter is inflated with saline and contrast agent and the exit site is dressed, allowing the patient to return later for brachytherapy treatment. As with many unlisted-procedure codes, you'll probably have to explain the nature of the procedure to justify your expenses.

Question: I received an op note that listed a pre- and post operative diagnosis of "bilateral accessory digits" and general anesthesia. Excisions of the small accessory digits were carried out with elliptical skin incisions. The physician repaired the incisions with simple interrupted sutures of 5-0 nylon, and applied sterile dressings. How should I report this?

Michigan Subscriber

Answer: You'll certainly need to use 11200* (Removal of skin tags/multiple fibrocutaneous tags, any area; up to and including 15 lesions) and, depending on the number of lesions, may also require add-on code 11201 (... each additional 10 lesions). Also report ICD-9 code 86.26 (Ligation of dermal appendage). While it may seem that there are multiple steps to this service (considering the prep work), the expense of the pre-op and dressings as routine supplies should be wrapped up in your charges for the procedure.