October 15, 2020 Question: Our patient had full thickness burn of foot and has been having serial debridements to the bone 25x17cm. Patient returned to operating room for another debridement down to the bone then reconstruction of foot with a muscle flap. For the debridements prior to flap closure, is it appropriate to code 11044...
October 15, 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....
October 15, 2020 Question: What would the correct CPT code be for a tracheostomy performed using a Bjork flap? I see some people stating it should be 31610. However, a Bjork flap is technically not a skin flap. I thought CPT 31610 was more for when a permanent stoma is created. Answer: CPT 31600 is...
October 15, 2020 Question: Our surgeon performed an aortogram with run-off to bilateral lower extremities. He then performed interventions in the left SFA and the left peroneal arteries. My question is regarding documentation of the diagnostic imaging Can he also bill for a diagnostic angiogram? What about catheterization to get there? Answer: Diagnostic imaging during...
October 15, 2020 Question: Our surgeon frequently documents in the procedure title that an arthroscopic subacromial decompression was performed. We are billing 29826 and are receiving denials from one particular payor stating that the documentation does not support the service. I am looking at the operative notes associated with these denials and see that in...
October 15, 2020 Question: A Medicare patient came in last week and my doctor did a biopsy on the chest and it came back malignant and meets the Medicare criteria for MOHS surgery. The patient came in today and he performed a level 3 E/M visit and did MOHS surgery in 2 stages. I am...
October 15, 2020 Question: The surgeon did a robotic/laparoscopic cholecystectomy and cholangiogram with icy green and firefly identification of biliary anatomy. He billed a 47563. Can he can bill separately for the icy green and firefly dye? Answer: Billing for indocyanine (ICG) or Firefly TM fluorescence is bundled into 47563 laparoscopic cholecystectomy with cholangiogram and is not separately billable. *This...
October 15, 2020 Question: I did an emergency craniectomy on a stroke patient 4 months ago. It is now time to reconstruct the defect and I’ll be doing that by placing some mesh and screws with Methyl methacrylate. Should I be using the 62140/62141 code series? Answer: Actually, CPT considers what you are doing to...
October 1, 2020 Question: For patients that are having surgery that day, I’ve been doing pre-op visits that morning (coming in earlier), and not doing a preop visit in clinic the week before surgery. Can I bill a follow up visit for the meeting/note (H&P) that occurs the morning of surgery? Answer: No – a...
October 1, 2020 Question: We have a patient who had knee surgery and required a return to the operating suite for treatment of a complication during the global period. We will bill the second surgery with a modifier 78. My supervisor is saying the aftercare needs to be extended another 90 days because the surgeon...
