January 9, 2020 Question: My provider insists on calling some lesions uncertain behavior because he is suspicious of cancer. This is before the pathologist has given a report. Should these be coded as uncertain behavior or unspecified? Answer: Uncertain behavior is a diagnosis that should only be assigned by a pathologist (with a path report)....
January 9, 2020 Question: We have a new physician who has joined our practice and is documenting use of cross links as well as the pedicle screws and rods is there an additional CPT I should be using for this? Answer: There is not a separate code for this as it is included in the...
January 9, 2020 Question: Physician was performing a spine injection and the patient chose to only have local anesthesia. During the procedure (before the medication was injected) the patient was uncomfortable and couldn’t tolerate the position, so the physician stopped the procedure. Would you use modifier -52 or modifier -53 for billing this? Answer: Since...
January 9, 2020 Question: I have a question about post op visits for PE tubes (code 69436). As you know, these have a 10 day global period but my group of physicians prefer to see these patients back in 4-6 weeks. They state 10 days is not enough time to verify the tubes are working....
January 9, 2020 Question: Is it appropriate to report CPT code 28645 for both traumatic and non-traumatic dislocations? Answer: Yes, CPT code 28645 (Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed) may be reported whether the nature of the dislocation is traumatic or non-traumatic, as long as the dislocation required an open...
January 9, 2020 Question: I’ve been dictating CPT and ICD-10-CM codes in my procedure note so that my coder knows what to bill. Recently, we had an insurance company call us out because the codes we billed were not the same as the codes in the procedure note. Now I am not sure what to...
January 9, 2020 Question: Is catheterization separately reported with renal angiograms? Answer: No. The renal angiogram codes, see table below, include all catherization. The codes are selected by order of catheterization and as unilateral or bilateral. Also, remember that a flush aortogram is included in the renal angiogram codes and not separately reported. CPT Code...
January 9, 2020 Question: Can you refresh my memory on when to use the diagnosis code for skin lesion “uncertain behavior” vs “uncertain behavior”? I know one is to be used before we get pathology results and one is for after, I just don’t remember which is which. If you could give me the ICD10...
December 19, 2019 Question: We are hiring a scribe for the doctor because it will help improve his documentation. Is there anything we need to know about how to document this? Answer: Yes, absolutely. This situation should be clearly delineated so a third party reviewer can identify the provider who performed the service, and the...
December 19, 2019 Question: One of our Providers recently completed Trigger Point injections to Bilateral Thoracic Paraspinals and Bilateral Trapezius in the same setting for a patient. When we bill for this procedure do we count each side (Left and Right) of these procedures as a muscle group to be billed out as 20553 OR each area...
