Month: April 2021

MDM Credit for 2021
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MDM Credit for 2021

April 29, 2021 Question:  I am a pain management specialist. I have a patient who was referred to my office who has dementia and was unable to provide her medical history. The patient’s granddaughter was able to provide the patient’s medical history to me as the patient was confused and unable to provide this information....

Laceration and Fracture Repair
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Laceration and Fracture Repair

April 29, 2021 Question: My physician is utilizing an open laceration on the patients chin for open reduction of a mandibular symphysis fracture. He wants to also charge for complex laceration repair for that laceration. Is this billable or is it part of the ORIF code? Answer: If the fracture is repaired through the laceration...

Fem-Fem Bypass
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Fem-Fem Bypass

April 29, 2021 Question: How is a left femoral to right femoral artery bypass with PTFE reported? Answer: Report code 35661, Bypass graft, with other than vein, femoral- femoral. This code applies to fem-fem bypass in the same leg or from one leg to the opposite leg. *This response is based on the best information...

Separate Procedure Billing
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Separate Procedure Billing

April 29, 2021 Question: I am new to coding and have a question. I remember studying about “separate procedures” and have my first operative note that includes a code that has this in the code definition. The surgeon performed a diagnostic arthroscopy (CPT code 29870) and confirmed the meniscal tear prior to proceeding with the...

Cerumen Removal
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Cerumen Removal

April 29, 2021 Question: If someone comes in for ear cleaning do you bill 69210 only or can you also bill an E/M code with modifier 25 and 69210? Answer: If the purpose of the encounter is for cerumen removal, as your scenario describes, then you would code only the cerumen removal (e.g., 69210).  Have...

OOOPs. I Nicked a Vessel. Can I Bill for Repairing it?
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OOOPs. I Nicked a Vessel. Can I Bill for Repairing it?

April 29, 2021 Question: The surgeon accidentally nicked a vessel not involved in the bypass being performed, can he bill for repair of vessel since he had to repair it? Answer: Iatrogenic, intraoperative complications that are repaired at the same operative session are not separately reported. Since the vessel laceration was an iatrogenic injury, inadvertently...

Modifier 52 vs. 53
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Modifier 52 vs. 53

April 15, 2021 Question: We are confused about the difference between modifier 52 and 53. What is the difference? Answer: Modifier 52 Reduced Services is used when the procedure or surgery is partially reduced or eliminated by the physician. This is used when a procedure has an existing CPT code, but not all of the...

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions
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Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 15, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the AMA (3/24/21 webinar), you should only document one or the other to prevent potential audit confusion and risk. Document time if billing by time OR...

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