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Hint: Know your anatomy and your resources for coding success.

In her HealthCon 2021 presentation 鈥淐oding for Common Procedures in a Primary Care Setting,鈥� Jaci J. Kipreos, CPC, CDEO, CPMA, CEMC, COC, CPC-I, president at Practice Integrity LLC, San Diego, outlined the pitfalls you can encounter when coding some of the numerous procedures you encounter in primary care.

You may think you鈥檙e familiar with many of these codes, and the problems associated with them, but because you might not see these them every day, and because they present some unique challenges, the following three procedures seemed especially worth a second look.

Dig Into Nail Trimming/Excising/Removal

鈥淚t seems simplistic, but the thing to remember about nails is to read the payer鈥檚 fine print,鈥� Kipreos advised. This is especially true when your provider is trimming nondystrophic, or essentially normal, nails using 11719 (Trimming of nondystrophic nails, any number). In this case, you must ensure medical necessity, which means documenting patient conditions, such as diabetes, that would allow for the procedure.

The key to coding nail avulsions and excisions using 11730 (Avulsion of nail plate, partial or complete, simple; single)/+11732 (鈥� each additional nail plate 鈥�) and 11750 (Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal) 鈥渋nvolves looking closely at the code descriptions and thinking about the different verbiage. This means knowing your nail anatomy,鈥� Kipreos points out.

So, provider documentation will have to note that the nail plate was partially or fully removed in the case of 11730/+11732, while excisions reported with 11750 should document the removal of the nail matrix, the part of the nail bed that produces the nail plate.

Check Out Trigger Point Injections (TPI)/ Dry Needling/Arthrocentesis

CPT^庐 codes 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)), 20553 (鈥� 3 or more muscles), 20560 (Needle insertion(s) without injection(s); 1 or 2 muscles), 20561 (鈥� 3 or more muscles), and the arthrocentesis, aspiration and/or injection with or without ultrasound codes (20600-20611) also present their own unique set of challenges.

First, 鈥渘o matter how small a procedure is, I have to see a procedure note. And I would love to know that the patient agreed to it; that risks, especially those unique to the individual patient, were identified; and that the patient was fine when it was over. That鈥檚 not a coding thing. That鈥檚 legal risk. And I want to make sure that everybody鈥檚 protected,鈥� Kipreos cautioned.

Then, you should familiarize yourself with any payer rules and local coverage determinations (LCDs) that govern use of these codes. Importantly, you need to be aware that there may be more than one LCD covering the same topic, one dealing with medical necessity and the other covering diagnosis codes.

Also, as you will code 20552, 20553, 20560, and 20561 鈥渂ased on the number of muscles injected, that means understanding muscle group anatomy. And it does not mean you shouldn鈥檛 document the number of injections the provider performed as well,鈥� Kipreos suggested.

Understanding musculoskeletal anatomy is key to using the arthrocentesis codes correctly as well, but so, too, is knowing whether you provider used ultrasound guidance to perform the procedure and whether the provider has entered a hard copy of the ultrasound image into the medical record.

Don鈥檛 forget: when reporting the TPI codes and many of the arthrocentesis codes, you should additionally document the injected drug by name and dosage.

What to Know About Coding Endoscopies

鈥淚f your office is choosing to provide endoscopies, you have to know anatomy and you have to know how far the scope has to go in order to get credit for the service,鈥� Kipreos advised. This means reacquainting yourself with the definitions provided at the beginning of the endoscopy section of CPT^庐 as well as familiarizing yourself with the colonoscopy decision tree in that same section. Knowing this information is key to accurate coding and avoiding denials.

For example, a diagnostic colonoscopy, which takes in the complete large intestine as far as the patient鈥檚 cecum (the junction of small and large intestine), is coded to 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), whereas a diagnostic colonoscopy that does not go beyond the splenic flexure (the curve to the left of the transverse colon) is coded the same way, but modifier 53 (Discontinued procedure) must be appended.

Colonoscopies used as a therapeutic procedures will involve different CPT^庐 codes altogether. You鈥檒l use 45331-45347 (Sigmoidoscopy, flexible 鈥�) if it does not reach the splenic flexure; 45379-45398 (Colonoscopy, flexible 鈥�) if it goes to the cecum; and 45379-45398 with modifier 52 (Reduced services) appended if the procedure goes beyond the splenic flexure but not to the cecum. The specific code you will bill for a therapeutic colonoscopy will depend on the nature of the service (for example, if your provider removed a foreign body or used the service to control bleeding).

Follow This Best Practice

鈥淎lways go through and double check as many different resources as possible to make sure you are coding both familiar and unfamiliar procedures correctly. That means going back over , the Office of Inspector General鈥檚 [OIG鈥檚] Work Plan at , your regional Medicare Adminstrative Contractor [MAC] directives, CPT^庐 and CPT^庐 Assistant, ICD-10, and private payer websites and policies. And use social networks responsibly, as you don鈥檛 know what sources they are using, and they may not know the MAC policies for your region,鈥� Kipreos cautions.