This article is the third in a series intended to provide coding tips from the National Correct Coding Initiative (NCCI) Policy Manual as they relate to correct coding for multiple procedures. Similar to the first two articles, the information presented is to help guide coding professionals determine when it’s appropriate to append a modifier to a code when a procedure-to-procedure (PTP) edit exists. For this particular article, we will focus on select guidance provided in Chapter 5, related to the Respiratory, Cardiovascular, Hemic and Lymphatic Systems classified under the CPT Code range 30000-39999. However, you may wish to refer to Chapter 5 the NCCI manual for additional and more complete information.
As a reminder, start by following the CPT guidelines, information within the code descriptors and parenthetical notes. For facility reporting on behalf of Medicare beneficiaries refer to the NCCI Policy Manual for Medicare, which can be found on the Centers for Medicare and Medicaid Services (CMS) website at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.
It is important to start by reporting the HCPCS/CPT code that most accurately describes the procedure performed. It is not appropriate to report a code if all of the services described by that code are not performed. Unbundling occurs when multiple codes are reported in place of a single HCPCS/CPT code that describes all of the services.
Similar to the information presented in the article related to the Musculoskeletal System published in the Fourth Quarter 2020 issue of Coding Clinic for HCPCS, the principles pertaining to arthroscopic procedures also apply to the endoscopic procedures of the Respiratory, Cardiovascular, and Hemic and Lymphatic Systems. Therefore, rather than repeating information that has been previously presented, we will address a few coding principles unique to the body systems presented in Chapter 5. The concepts similar to arthroscopic procedures include:
- Guidance such as diagnostic endoscopies are inherent to surgical endoscopies
- When a surgical endoscopic procedure is converted to open, the open and not endoscopic procedure is coded.
- Biopsies performed during a more extensive procedure are not reported separately.
- A feature of the respiratory system is that the nose and mouth have mucocutaneous margins and include procedures classified with CPT codes that describe some procedures in the integumentary system, nasal (respiratory) and oral (CPT code range 4000-40899). Procedures performed on lesions at or near a mucocutaneous margin are reported with a single code that best describes what was performed. If a code from the respiratory system includes a tissue transfer, such as a flap or graft, the appropriate integumentary code may be additionally reported. It is important to note that this advice is not unique to the respiratory system.
- When diagnostic or surgical endoscopies of the respiratory system are performed, evaluation of the access regions are included and not separately reported. For example, when performing a transnasal endoscopic sinus procedure, an endoscopy of the nose is not separately reported when the nose is the access point for the endoscope. However, if two separate regions are examined, utilizing two types of endoscopes, both procedures may be reported when deemed medically necessary.
- Separate codes are not assigned for control of bleeding with endoscopic procedures as the control of bleeding is considered an integral component.
- It is not appropriate to report both flexible and direct laryngoscopies for the same patient encounter.
- When emergency endotracheal intubation is performed, a chest x-ray to confirm correct positioning of the endotracheal tube is not separately reportable. This also applies to confirmatory chest x-rays for insertion of chest tubes and pleural drains.
- When a laryngoscopy is required for placement of a tracheostomy, assign a code for the tracheostomy only. It is not appropriate to additionally report the laryngoscopy.
- When coding vascular procedures, the repair and closure of the vessel utilized for access is inherent to the primary procedure and not separately reported.
- When both percutaneous and open vascular procedures are performed on separate and distinct lesions in separate anatomically defined vessels, both procedures may be reported with a modifier 59, Distinct Procedural Service, appended. It is not appropriate to separately report open and percutaneous procedures when performed in the same anatomically defined vessel, in that example only the open procedure is reported.
- It is not appropriate to separately report sample collection when an existing vascular access line or selectively placed catheter is utilized to procure arterial or venous samples.
- Codes representing venous access are not separately reported when the access is routinely performed as part of performing another medical, diagnostic or surgical procedure. It is not appropriate to assign a code for venous access when the access is necessary to accomplish a procedure such as infusion therapy or chemotherapy or for infusions performed to maintain patency of a vascular access site. Examples of CPT codes representing venous access include codes 36000, Introduction of needle or intracatheter, vein, 36406, Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; other vein, and 36410, Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture).
- When a diagnostic angiogram is performed prior to the date of an intravascular interventional procedure, a second diagnostic angiogram may not be reported on the date of the procedure. The exception to this guidance is when a second diagnostic angiogram is medically necessary to further define the anatomy and pathology. In that case, the second angiogram is reported with a modifier 59 appended.
- Superficial or deep implant removal represented by CPT codes 20670, Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure), and 20680, Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate), are not additionally reported when the removal is integral to another procedure. For example, if a re-operation requires removal of previously placed wires in order to accomplish the procedure, the removal is not separately reported.
- Repair of transvenous electrodes is captured with CPT codes 33218, Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator, and 33220, Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator. These codes include incising the skin pocket, removing the device, fixing the lead and reinserting the original device. When the original device is removed, repaired, and reinserted, it is not appropriate to separately report CPT codes for device removal, insertion, replacement or skin pocket revision. However, if the original device is replaced with a new device, CPT codes 33227-33229 or 33262-33264 may be additionally reported.
Hemic and lymphatic systems
- Bone marrow aspiration and bone marrow biopsy are represented by two different CPT codes, 38220, Diagnostic bone marrow; aspiration, and 38221, Diagnostic bone marrow; biopsy(ies). These codes may not be reported together when a bone marrow aspiration and biopsy are performed at the same site. Instead, CPT code 38222, Diagnostic bone marrow; biopsy(ies) and aspiration(s), is appropriately reported. In addition CPT code 38221 may not be reported with CPT code 20220 (bone biopsy). CPT codes 38220 and 38221 can only be reported together if performed on different bones or at separate encounters.
Following are Q&A’s to illustrate this guidance.
A patient with a lateral tongue lesion presented for biopsies and laser ablation of the lesion. The procedure began with a laryngoscopy utilizing the GlideScope with no additional lesions identified. Once the laryngoscopy was completed laser ablation of tongue lesion was performed followed by small incisional biopsies from anterior to posterior, superior and inferior of the lesion. Is it appropriate to assign codes for the laryngoscopy and biopsies in addition to the laser ablation of the tongue lesion?
It is not appropriate to additionally report the laryngoscopy. When diagnostic or surgical endoscopies of the respiratory system are performed, evaluation of the access regions are included and not separately reported. It would also be inappropriate to separately report biopsies taken of the same lesion procured as part of the surgery. The biopsies were not performed to establish the need for surgery in this case.
A patient was admitted to Observation and a peripherally inserted central catheter (PICC) line was placed for intravenous (IV) infusion administration services. The following morning, labs were ordered and blood was drawn from the previously placed PICC line.
Does the fact that the PICC was placed for medication administration mean that CPT code 36592, Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified, cannot be reported for the collection of the blood specimen? CPT guidance in the parenthetical under code 36592 states “Do not report 36592 in conjunction with other services except a laboratory service.”
Although the specimen was drawn for a lab test, it would not be appropriate to report CPT code 36592 for the procurement of the specimen from a PICC previously placed for medication administration. When existing vascular access line(s) or selectively placed catheter(s) are utilized to procure arterial or venous samples, reporting of the blood draw separately is inappropriate.
A patient presented for a bone marrow aspiration and biopsy. The documentation states that an 11-gauge needle was advanced into the right ilium and a routine bone marrow aspiration and biopsy was performed. However, the technique utilized is not documented. Is the correct code assignment CPT 20220 or 38222?
When the documentation supports a bone marrow aspiration and a bone marrow biopsy are performed, assign CPT code 38222, Diagnostic bone marrow; biopsy(ies) and aspiration(s). CPT code 20220, Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs), is assigned to capture a biopsy of the bone, not bone marrow. The parenthetical note at CPT code 20220 instructs “For bone marrow biopsy[ies] and/or aspiration[s], see 38220 38221, 38222.”