Surgical procedures as defined by Current Procedural Terminology (CPT) can be performed by any physician licensed to do so. While bone surgeries are normally the purview of orthopedic surgeons, some internists do perform uncomplicated soft tissue surgeries in the outpatient setting. A certified medical coder or medical biller will be able to assign the correct code to describe the service performed in order to receive accurate and prompt reimbursement.
Musculoskeletal procedures include a global package of services. This package includes the materials supplied by the physician in order to successfully perform the surgery, as well as the administration of anesthesia in the office. This includes local anesthesia and its delivery, such as the injection of lidocaine at the surgical site. The injection is not coded separately since it is considered an integral component of the main procedure. Immediate post-operative care is also considered integral to the main procedure and additional evaluation and management codes are not billed to provide post-op instructions, prescriptions, etc., that are related to the surgery.
When more than one surgery is performed by the same physician at the same encounter, the applicable codes may require modifiers to differentiate the two independent services. A biopsy of one tumor and the excision of another tumor at the same anatomical location requires that a modifier -59 be applied to the biopsy. The submission of excised tissue to a pathologist for definitive diagnosis is considered integral to an excision — meaning a biopsy and excision cannot be reported for the same surgical encounter.
A biopsy is the removal of a representative sample of tissue to confirm a suspected diagnosis. Not all biopsies are the same. CPT advises that a needle biopsy is coded differently from a superficial, subdermal biopsy, and also from a deep excision from beneath the fascial layer or inside the muscle strata. A professional medical documentationist is restricted to use only those codes that are substantiated in the contents of the medical record. When a procedure is described only as a biopsy, it cannot be coded as a more extensive excision. In order to avoid confusion during an audit of available documentation, surgical procedures should be described as closely to CPT terminology as possible. An excision should not be referred to as an excisional biopsy, since a biopsy carries its own distinct code regardless of size.
A medical doctor, as opposed to a surgical doctor, may choose to excise a small benign tumor from a large muscle such as from the upper arm. The appropriate excision code includes not only the tumor itself, but also the margins. In order to ensure that the entire tumor is removed, surrounding healthy tissue is excised around the tumor’s margins. The total size of the excision dictates accurate CPT code assignment, not the size of the tumor. A soft tissue tumor measuring 2.9 centimeters at its largest dimension with margins that measure an additional half centimeter from the upper arm is coded 24071 (greater than 3 cm), not 24075 (up to 3 cm). Note that CPT does not differentiate between a benign or malignant soft tumor excision from the upper arm.
CPT does differentiate between an excision and radical resection of soft tissue tumors from the upper arm. A radical resection is normally reserved for malignant tumors. It is unlikely that any physician other than a surgeon will perform a radical resection. If another healthcare provider describes a tumor removal as a radical resection, the documentation should be closely reviewed to safely guarantee that more than one type of tissue has been removed, such as associated lymph nodes or bone.
As with any field of medical coding and medical billing, physicians are not always aware of all the issues involved in submitting accurate medical claims. This is why they employ professional, certified medical documentation specialists and billers to assemble clean claims according to industry standards. This not only ensures legally accurate reimbursement when the claim is paid, it also ensures that money will not be recouped or fines be charged in the event of a post-payment audit by an insurer, Medicare or Medicaid.