Month: January 2020

Two Level ACDF (non-contiguous)
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Two Level ACDF (non-contiguous)

January 23, 2020 Question: Our surgeon performed an ACDF at C2-3 and C6-7 through separate incisions for treatment of anterior fractures. We are wondering if we are able to report 22551 twice or if we should use the add-on code, 22552; this is rare for our practice and we think we should use the primary...

Keloid Scar Destruction
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Keloid Scar Destruction

January 23, 2020 Question: What CPT code should you report for laser removal of a keloid scar? What should be documented in the procedure note? Answer: You would report 17110. Documentation should always include: Indications for procedures Risks/Benefits Document location of lesion/keloid destroyed CM size of lesion before removal/destruction Method of destruction Detail of the...

Ear Exam Under Anesthesia
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Ear Exam Under Anesthesia

January 23, 2020 Question: Our surgeon performed an evaluation of the external ear canal on a pediatric patient, under general anesthesia, because the child would not allow the surgeon to evaluate the ears thoroughly in the office. We cannot find a CPT code for this service. Do we use an unlisted code? Answer: CPT code...

Catheterization Codes in Vascular Coding
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Catheterization Codes in Vascular Coding

January 23, 2020 Question: Are there any vascular CPT codes that still allow separate reporting of selective and non-selective catheterization codes? Answer: Yes, the following procedures still allow separate reporting of catheterization codes Non- lower extremely, stenting, angioplasty, for example subclavian or renal arteries Peripheral embolization, for example hypogastric artery embolization during EVAR or uterine...

Laceration and Fracture Repair
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Laceration and Fracture Repair

January 23, 2020 Question: My physician is utilizing an open laceration on the patient’s chin for open reduction of a mandibular symphysis fracture and he wants to also charge for a complex laceration repair for that laceration. Is this billable or is it part of the ORIF code? Answer: If the fracture is repaired through...

Coding for Non-Biological Mesh Placement
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Coding for Non-Biological Mesh Placement

January 23, 2020 Question: How do I report placement of a mesh implant in the abdomen that is not a biological implant and not for an open incisional hernia? Answer: Placement of a non-biological implant in the abdomen is reported with code +0437T Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of...

MIPS 2020:  Don’t Be Caught with a 9% Medicare Payment Reduction
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MIPS 2020: Don’t Be Caught with a 9% Medicare Payment Reduction

January 22, 2020 As MIPS enters its fourth year, the penalty for not participating rises to 9%. CMS retired 42 quality measures in 2020 including measures specific to orthopaedics, otolaryngology, neurosurgery, vascular surgery, PMR, as well as others. So whether you have been participating all along or 2020 is your first year, there are new...

Unspecified or Uncertain Behavior
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Unspecified or Uncertain Behavior

January 9, 2020 Question: My provider insists on calling some lesions uncertain behavior because he is suspicious of cancer. This is before the pathologist has given a report. Should these be coded as uncertain behavior or unspecified? Answer: Uncertain behavior is a diagnosis that should only be assigned by a pathologist (with a path report)....

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