Month: September 2019

Five Tips to Ensure Your E/M Documentation Will Pass an Audit
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Five Tips to Ensure Your E/M Documentation Will Pass an Audit

September 25, 2019 Documentation in every setting begins and ends with the physician/advanced practitioner. It is not the quantity but the quality of the documentation that counts. Documentation is supported in the detail. When I work with physicians on clinical documentation, the question that always comes up is: “What do I need to document to...

Iliac Artery Aneurysm Treatment Coding
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Iliac Artery Aneurysm Treatment Coding

September 19, 2019 Question: How do I code for an isolated iliac artery treated endovascularly with an iliac endograft? Answer: These codes were revised in 2018 to include either ruptured or unruptured iliac aneurysms. In addition, non-selective catheterization and radiological supervision and interpretation are now inclusive. The full code descriptions are shown below. The CPT...

Coding for Percutaneous Tracheostomy
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Coding for Percutaneous Tracheostomy

September 19, 2019 Question: What code is used for percutaneous tracheostomy? Answer: Code 31600 is reported for “percutaneous” tracheostomy. This procedure is performed with a small incision and some direct visualization of the structures with or without a bronchoscope. The bronchoscope, used as a light source and to remove blood and secretions, is NOT separately...

Stem Cell Implant Knee Osteoarthritis
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Stem Cell Implant Knee Osteoarthritis

September 19, 2019 Question: Our surgeons are harvesting adipose tissue and creating an injectable implant that they are injecting in the knee for treatment of osteoarthritis. We want to verify that our use of an unlisted CPT code is correct. We have some payors who do reimburse for this service; others require the patient to...

Intraoperative Testing of the IPG
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Intraoperative Testing of the IPG

September 19, 2019 Question: Can I code 95971 for intraoperative testing of the implantable pulse generator (IPG) when the spinal cord stimulator is placed? The operative note says “intraoperative testing was performed to confirm the appropriate connections.” Answer: CPT guidelines state “test stimulation is not considered electronic analysis or programming” and “is included in the...

Waiting on Pathology?
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Waiting on Pathology?

September 19, 2019 Question: Do you have to await the pathology report in order to assign the diagnosis of benign or malignant for a lesion; when reporting destruction codes 17000-17111 or any lesion removal codes? Answer: There are multiple answers to your question depending on which piece is addressed. I will try to address them...

Use of a Scribe
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Use of a Scribe

September 19, 2019 Question: We are hiring a scribe for the doctor because it will help improve his documentation.  Is there anything we need to know about how to document this? Answer: Yes, absolutely. This situation should be clearly delineated so a third party reviewer can identify the provider who performed the service, and the...

Prescription Refill Visits
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Prescription Refill Visits

September 19, 2019 Question: We get calls from patients to renew their medications. When the patient comes to office to pick up prescription, can we bill for a nurse visit with 99211? Answer: No. CPT makes it very clear that picking up a prescription does not constitute a billable E/M service. *This response is based...

Don’t Skip These 8 Orientation Essentials
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Don’t Skip These 8 Orientation Essentials

September 17, 2019 Rushing staff orientation and jumping right into training can be a costly mistake. To be an effective ambassador for your practice, each staff must understand the practice’s brand and culture, the physician’s style, and what makes the patient’s experience with you unique from competitors. Think of orientation as “pre-training.” Orientation provides the...

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