Category: Coding Coach

Unspecified or Uncertain Behavior
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Unspecified or Uncertain Behavior

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)....

Modifier -52 or -53
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Modifier -52 or -53

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...

Dislocation CPT Codes: Traumatic vs Non-traumatic
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Dislocation CPT Codes: Traumatic vs Non-traumatic

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...

Renal Angiogram Coding
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Renal Angiogram Coding

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...

Use of a Scribe
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Use of a Scribe

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...

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Coding Coaches