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...
March 4, 2021 Question: We do a lot of hand surgery and have an x-ray machine in the office. This has made me confused about how to count the data for the neurosurgeon’s E/M code. Please help. Answer: Good question and let’s simplify things. The AMA specifically states there should be “no incentive”, related to...
March 4, 2021 Question: Does TEVAR allow for billing of catheterization and intervention? Would a 59 modifier be needed? Answer: Yes, billing for a catheterization in addition to the TEVAR is allowed. And no, a modifier 59 is not needed as these two codes do not bundle. *This response is based on the best information...
March 4, 2021 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...
March 4, 2021 Question: I was asked, by a new spine surgeon in town, to do the cervical approach for an anterior cervical decompression and fusion. Do I use a regular neck dissection code such as 38724? Answer: Oh no, 38724 is for a modified radical neck dissection requiring removal of lymph nodes. The cervical...
March 4, 2021 Question: My physician excised a lesion the was 1.5cm on the trunk. He documented it as a benign lesion but sent it to pathology for confirmation. We submitted CPT code 11402 for the benign lesion of the trunk. The lesion came back malignant. Shouldn’t we wait for the pathology report prior to...
March 4, 2021 Question: A major blood vessel was accidentally nicked while a general surgeon was performing a complex case. A vascular surgeon was called in to repair the blood vessel. Since they are different specialties, can the vascular surgeon bill for the repair, even though she is in the same group as the general...
March 4, 2021 Question: Would bilateral L4-L5 herniated discs count as 2 problems in the new E/M guidelines for office visits? Answer: No because these two problems are at the same spinal level and are treated with the same procedure (discectomy). Therefore, it counts as 1 problem. *This response is based on the best information...
February 18, 2021 Question: Would bilateral large breasts, on a patient that we are recommending breast reduction, count as 2 problems in the new E/M guidelines for office visits? Answer: No because these two problems will have the same concurrent treatment (breast reduction). Therefore, it counts as 1 problem. *This response is based on the...
February 18, 2021 Question: I’ve heard that all you need to document for family history is the word “none”, and that would count as documenting. Is this enough? Answer: No. Documenting “none” is saying that the patient does not have a family history, and this would not be accurate as we all have a family...
