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Reader Questions: Watch Frontal Sinuses With Ethmoidectomy

Question: The physician uses a scope to inspect the patient's frontal recess. While performing an ethmoidectomy and an antrostomy, the doctor also fractures and subluxes the agger nasi cells to establish patency. How should I report this?

Kentucky Subscriber

Answer: The report reflects that the physician did not clean out frontal recess cells, polyps or scar tissue - and he didn't venture into the frontal sinus area. Therefore, you should report code 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) for the total ethmoidectomy. This procedure also includes 31254 (... with ethmoidectomy, partial [anterior]).

Know Payer for Bladder Lesion

Question: The physician performed a transurethral resection of several malignant bladder lesions of varying sizes. Should I bill according to the number of tumors or according to their combined weights?

California Subscriber
  
Answer: When the physician removes more than one bladder tumor, selecting a code or codes based on the size or number of tumors may seem reasonable, but don't jump the gun.
  
CPT guidelines lack clarity when describing bladder lesion removal (52234, 52235 and 52240), but Medicare has a more definite policy: You should bill only one of the tumor removal codes, reporting only the largest tumor the physician resects.
  
Private payers, on the other hand, are a different story. If you report 52234, 52235 or 52240 to a non-Medicare insurer, you should add together the tumor sizes and report the code that best represents the total tumor volume.
  
The physician bases the documented tumor size on a visual estimate of the tumor at cystoscopy. Select the tumor removal code based on this estimate. Use 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]) for tumors measuring between 0.5 cm and 2.0 cm, 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for tumors between 2.0 and 5.0 cm, and report 52240 (... LARGE bladder tumor[s]) for anything larger than 5.0 cm.
  
For bladder biopsies at different bladder sites significantly removed from the original tumor resection, you should report codes 52204 (Cystourethroscopy, with biopsy) and/or 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy). Be sure to append modifier -59 (Distinct procedural service) to indicate to the payer that the procedure was separate.

Use One Code for J-Tube Conversion

 Question: The doctor's documentation says that he changed a feeding tube from a G-tube to a J-tube. What's the difference? Should I report just the G-tube, the J-tube, or both?

New Mexico Subscriber

 Answer: The primary difference between a G-tube (percutaneous gastrostomy tube) and a J-tube (percutaneous jejunostomy tube) is that the physician inserts the G-tube into the stomach, while the J-tube goes directly into the jejunum. Both are feeding tubes required by patients unable to consume enough calories to sustain their metabolisms.
 
Physicians usually insert these tubes for patients who have trouble swallowing, who have neoplasms of the esophagus or larynx, or who have  other catabolic conditions.
 
For a G-tube placement, you should report 43750 (Percutaneous placement of gastrostomy tube). If the physician's notes mention "PEG buttons" or "Mickey buttons," you should use code 43760 (Change of gastrostomy tube), because these terms refer to small tubes the doctor inserts to replace the G-tube.
 The conversion from a G-tube to a J-tube means the physician had a G-tube in place but inserted it into the small bowel, past the duodenum, at which point you call it a J-tube. In the scenario you described, you should report only 43761 (Repositioning of the gastric feeding tube, any method, through the duodenum for enteric nutrition).
  
 - Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. Consulting in Raleigh, N.C.