Month: December 2020

Need Help with a Diagnosis Code
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Need Help with a Diagnosis Code

December 17, 2020 Question: We had a patient who came in for management of chronic right hip pain. I am new to pain management coding and not sure what diagnosis code to use. Can you help? Answer: Certainly. First based on the ICD-10-CM Official Guidelines for Coding and Reporting the first listed diagnosis code is...

New 2021 E/M Coding Guidelines
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New 2021 E/M Coding Guidelines

December 17, 2020 Question: In the new guidelines, how does Time affect billing for a teaching physician’s E/M service when the resident spends a great deal of time with the patient? Answer: Good question! Only the time of teaching physician would “count” in the scenario you describe. The new guidelines say that the time of...

Carotid Artery Exploration with Free Flap to Oral Cavity
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Carotid Artery Exploration with Free Flap to Oral Cavity

December 17, 2020 Question: Can we report 35701 for the carotid vessel exploration in the recipient site when doing a fibula free flap (20969)? Answer: No, this activity is included in the free flap code. CPT specifically states not to 35701 to explore and identify a recipient artery [eg, external carotid artery] when performed in...

Wedge Excision with Reconstruction
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Wedge Excision with Reconstruction

December 17, 2020 Question: My physician did a full thickness wedge excision with an Estlander flap of the right upper lip with reconstruction utilizing a cheek flap, adjacent tissue transfer. The defect measures 27 sq. cm. The physician used a mucosal graft from the wedge excised from the lip with reconstruction of the vermillion of...

Coding 23395 for Pectoralis Muscle Repair
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Coding 23395 for Pectoralis Muscle Repair

December 3, 2020 Question: Someone told us to bill 23395 for repairing the pectoralis muscle after removing breast implants. Here’s the common scenario: Removal of old bilateral breast implants with capsulectomies Repair of pectoralis muscle with re-attachment to chest wall Creation of pre-pectoral pocket with acellular dermal matrix Placement of bilateral breast implants for reconstruction...

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