July 9, 2020 Question: I took out 3 deep cervical nodes for biopsy on the left side. Can I bill 38510 x 3? Answer: No – you’d report 38510 once for any number of nodes removed from the same incision. *This response is based on the best information available as of 07/09/20.
July 9, 2020 Question: I’m a pediatric orthopedic surgeon. Some of my team are reporting the NPWT codes 97605 and 97606 when applying wound vacs after closing at the completion of their surgical cases. As a result, I am told by my coders that NCCI Standards of Medical Practice edits are being generated. The NCCI guidelines define the...
July 9, 2020 Question: I placed subdural stereo-EEG electrodes for epilepsy monitoring. What is the code for removal of these electrodes? I’ve been billing 61880 for removal of each electrode up to 10 or 13 units depending on how many electrodes I remove. My new coder said she’s not sure we are using the correct...
July 9, 2020 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 be false as we all have a family history....
July 9 , 2020 Question: My physician removed a soft tissue tumor on the patient’s foot measuring 1.2 cm. Documentation indicates subcutaneous. He is coding this as a benign excision and wants to report CPT code 11422. Can you tell me if this is correct? Answer: The correct CPT code to report is CPT code...
July 9, 2020 Question: Code 64615 says bilateral for the injection of Botox for chronic migraine. Does that mean we can also bill 95873 twice? Answer: Although not explicitly stated in the name for 95873, CPT gives guidance in parentheses to only code one unit of any guidance code when billing 64515. So you would...
July 9, 2020 Question: I did a right anterolateral thigh free flap and had to close the right thigh wound (4 x 8 cm) with undermining of additional 3 cm in either direction to close the wound without any significant tension. Can I also code a complex repair (13100, +13101) with the free flap code?...
July 9, 2020 Question: I’m new to vascular coding, can we bill for vascular access for a catheterization? The provider documents this, so I’m thinking I am missing a code. Answer: No, vascular access itself is not separately billable with a catheterization. However, the provider must document if access was obtained on the same side...
June 25, 2020 Question: When placing pedicle screws, do I bill per pedicle screw or per level? For example, pedicle screws and rods at L5-S1, is it 22840 x 4 units or just 22840? Answer: The posterior spinal instrumentation codes are used once per construct. So pedicle screws and rods at L5-S1 is 22840 only....
June 25, 2020 Question: Can I bill for different diagnosis codes for conditions/problems when seeing a patient in the hospital after surgery, but during the stay of a major surgery? Answer: It depends. You cannot bill for related issues or known complications that arise from the surgery, but you can bill for unrelated conditions/problems with...
