Month: March 2021

E/M Guidelines for 2021
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E/M Guidelines for 2021

March 18, 2021 Question: My physicians have decided they would prefer to continue to use the E/M 1995/1997 guidelines for office visits instead of the new 2021 guidelines. Do we have a choice? Can we continue to use these guidelines? Answer: The new guidelines apply to office or other outpatient services 99202-99215 and are based...

Oncoplastic Reconstruction
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Oncoplastic Reconstruction

March 18, 2021 Question:  I just realized CPT 19366 was deleted in 2021. Now what code do I use for an oncoplastic reconstruction? Answer: You’re right – CPT 19366 (Breast reconstruction with other technique) was deleted this year. You will code for whatever procedure you end up doing such as an adjacent tissue transfer (e.g.,...

Venogram and Catheterization
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Venogram and Catheterization

March 18, 2021 Question: During a catheterization the surgeon performed a venogram. I don’t see that these procedures are bundled, is that correct? Answer: Venous catheterization codes are separately reported with venograms, unless they are performed at the same session with an intervention that includes catheterization. *This response is based on the best information available...

Medication Documentation
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Medication Documentation

March 18, 2021 Question: We are switching to a new EHR system. We have not always had great compliance with our providers documenting what we feel needs to be documented so we want to do it right. Are you able to advise what should be included in the medical record when the provider administers medications,...

Modifier 58 vs. Modifier 78
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Modifier 58 vs. Modifier 78

March 18, 2021 Question: Do some insurance carriers want modifier 58 and others want 78?  What is the difference in these modifiers? Answer: Modifier 58 is used on a subsequent surgery when a planned (or staged) related procedure is performed within the global period of the first surgery. If possible, but not required, the surgeon...

Bone Filler Allograft
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Bone Filler Allograft

March 4, 2021 Question: We have a surgeon who performed an ORIF of an open tibia fracture and placed bone filler allograft in an area where the surgeon felt there was a small bone void. Is this work considered bundled or not? Neither the surgeon or I think it is billable but thought we should...

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