2023 ASC Coding Tips: The Impact Devices Have on Coding

Mandeara Frye, RHIA, CPC, CPMA, CRC, CASCC, Senior Director, Coding

As technology advances, we are seeing more and more devices become available that increase patient safety and physician skill while decreasing the need for invasive treatments. For physicians who are documenting and staff who are coding procedures that include devices, it’s important to understand what impact devices have on code selections.

Physician Tip

Rather than titling your procedure by the device used (e.g., Omni procedure), use the clinical term for it (e.g., dilation of Schlemm’s canal). This will help your coders accurately identify the correct procedure performed and avoid confusion or possible queries if they don’t understand how the device translates to the performed procedure.

Coder Tip

Understand the multiple uses for medical devices, and don’t code based solely on the device. The Omni device mentioned above is a great example. We most often see the Omni device used to perform canaloplasty/transluminal dilation/dilation of Schlemm’s canal, which would translate to CPT 66174. The device can also be used to perform a goniotomy, coded with 65820, so it’s imperative to read the operative report in its entirety and understand the actual procedure being performed.

Another example in ophthalmology is implantation of an XEN gel stent. We most commonly associate such devices with Category III code 0449T. However, depending on the surgical approach and where the stent is placed in the eye, these can also be reported with CPT 66183.

This guidance applies to other specialties as well. For instance, in orthopedics, we may see a Topaz device used to perform a tenotomy or fasciotomy. According to September 2009 issue of AMA CPT Assistant September, Topaz is a “tool and not a procedure, [so] code selection will depend on the service performed, and the specific anatomy involved, as it can be used on different parts of the body.”