Author: The Coding Coach (Coding Coach)

SI and Trigger Point Injections
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SI and Trigger Point Injections

June 6, 2019 Question: A patient comes to our office for a sacroiliac joint injection and is also requesting a cervical trigger point injections as he woke with a stiff neck.  The physician evaluated the patient and performed a right SI joint injection and also injected 4 spots along the left trapezius.  Fluoroscopy is used...

Diagnosis Code
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Diagnosis Code

June 6, 2019 Question: A pathology report came back from a skin biopsy stating “compound dysplastic lesion with severe atypia.  Re-excision recommended.”  Should the diagnosis code be D48.5 for lesion of uncertain behavior of the skin be assigned, or a benign code since it does not state it is malignant? Answer: Since the pathology notes...

Intraoperative Ultrasound for Tumor Removal
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Intraoperative Ultrasound for Tumor Removal

June 6, 2019 Question: My surgeon uses the intraoperative ultrasound to assist with a brain tumor removal. I am billing 76998 with modifier 26 for the professional component.  Sometimes we don’t get paid.  Should I appeal these denials? Answer: No….actually, intraoperative ultrasound is included in the global surgical package for the neurosurgeon and should not...

Billing for an iatrogenic injury, my patient.
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Billing for an iatrogenic injury, my patient.

June 6, 2019 Question: The surgeon reported an intestinal perforation caused by a trocar during a laparoscopic cholecystectomy due to extensive adhesions.  He completed the cholecystectomy and also did a suture repair of one perforation of the small intestine. How is this reported? Answer: Iatrogenic, intraoperative complications that are repaired at the same operative session...

Ear Biopsy
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Ear Biopsy

May 23, 2019 Question: What is the correct code for a tangential biopsy of the antihelical fold?  I was going to bill 11102, but I was told that there are different codes in other sections of CPT for some biopsies. Answer: The correct code would be 69100, Biopsy external ear.  As a bonus, this correct...

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Coding Coaches