Category: Coding Coach

Incident to Services
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Incident to Services

April 1, 2021 Question: One of our physician assistants’ saw one of our established Medicare in the emergency room for increasing pain in the area being treated by the physician. The physician assistant made no changes to the plan of care established by the physician. Our physician assistant submitted this as an incident to service...

Lesion Crossing Two Territories
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Lesion Crossing Two Territories

April 1, 2021 Question: Our vascular surgeon did a single intervention on a lesion that was at the juncture of the femoral/popliteal and tibial/peritoneal territories. Can we charge for two interventions? Answer: Lesions that extend across the margins of one vessel vascular territory into another, but can be treated with a single therapy are reported...

Coding an Epidermal Inclusion Cyst
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Coding an Epidermal Inclusion Cyst

April 1, 2021 Question: I excised an EIC lesion on the chest.  I coded this as D48.5 but my coder says this is the wrong diagnosis code.  What is the correct diagnosis code? Answer: ICD-10-CM code D48.5 (Neoplasm of uncertain behavior of skin) is incorrect as you have stated the patient has an EIC (epidermal...

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 1, 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...

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.,...

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Coding Coaches