AMA CPT® Assistant - 2020 Issue 5 (May)
Frequently Asked Questions (May 2020)
May 2020 page 13 Frequently Asked Questions Surgery: Integumentary System Question: A left temple lesion suspicious for a non-melanoma skin cancer is biopsied via the tangential technique (shave, scoop, saucerize, or curette). After the biopsy is performed, it is noted that the depth of the biopsy reached the subcutaneous fat in its deepest portion. Which is the most appropriate CPT biopsy code to report for this procedure, tangential or incisional biopsy? Answer: A tangential biopsy performed via shave, scoop, saucerize, or curette that inadvertently penetrates the subcutaneous space does not fully rise to the level of an incisional biopsy...
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Article Overview
This article compiles May 2020 CPT Assistant questions and answers spanning several surgical and laboratory subjects. It is useful for coders, billers, auditors, and clinical documentation staff who need a high-level understanding of how the CPT code set addresses common reporting scenarios, supporting documentation, and modifier usage across different specialties. The piece focuses on practical guidance related to service selection, bundled component issues, repeat or additional procedures, and documentation expectations.
Why This Topic Matters
The FAQ format highlights recurring documentation and reporting issues that can affect code selection, claim accuracy, and compliance across multiple specialties. It is especially relevant for teams reviewing CPT-based reporting practices and modifier application in a busy clinical environment.
Article Sections
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Surgery: Integumentary System
Questions and answers involving skin biopsy reporting and CPT code selection in the integumentary system.
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Surgery: Cardiovascular System
Guidance on reporting an endovenous ablation service in the cardiovascular system section of CPT.
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Surgery: Digestive System
Discussion of endoscopic mucosal resection reporting, included components, and related digestive system coding considerations.
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Surgery: Musculoskeletal System
A musculoskeletal coding question addressing arthroscopy-related reporting and inclusion issues.
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Surgery: Nervous System
Multiple questions covering spinal reexploration, facet-related ablation, and other nervous system surgical reporting topics.
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Pathology: In Vivo (eg, Transcutaneous) Laboratory Procedures
A laboratory and pathology question involving a transcutaneous test performed in an office setting and its relationship to E/M reporting.
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Appendix A: Modifiers
An appendix-based discussion of modifier usage and the documentation expectations associated with increased procedural services.
What You Will Learn
- How this CPT Assistant FAQ article is organized by surgical and pathology topic
- Which broad reporting issues are addressed in skin, cardiovascular, digestive, musculoskeletal, nervous system, and laboratory services
- What kinds of documentation and modifier questions are discussed in the article
- How the article frames bundled service and separate reporting scenarios at a high level
Who Should Read This
- Medical coders
- Professional billers
- Compliance auditors
- Revenue cycle staff
- Physician documentation staff
- Coding educators
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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