December 17, 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 not be accurate as we all have a family...
Category: Coding Coach
New 2021 Evaluation and Management Code Guidelines
December 17, 2020 Question: I heard that the E/M code guidelines are changing in 2021. Will this apply to all E/M codes? Answer: Good question. The 2021 changes will NOT apply to all E/M codes. The 2021 changes apply only to the new patient, 9920x, and established patient, 9921x, categories of codes. That means you...
Need Help with a Diagnosis Code
December 17, 2020 Question: We had a patient who came in for management of chronic right hip pain. I am new to pain management coding and not sure what diagnosis code to use. Can you help? Answer: Certainly. First based on the ICD-10-CM Official Guidelines for Coding and Reporting the first listed diagnosis code is...
New 2021 E/M Coding Guidelines
December 17, 2020 Question: In the new guidelines, how does Time affect billing for a teaching physician’s E/M service when the resident spends a great deal of time with the patient? Answer: Good question! Only the time of teaching physician would “count” in the scenario you describe. The new guidelines say that the time of...
Carotid Artery Exploration with Free Flap to Oral Cavity
December 17, 2020 Question: Can we report 35701 for the carotid vessel exploration in the recipient site when doing a fibula free flap (20969)? Answer: No, this activity is included in the free flap code. CPT specifically states not to 35701 to explore and identify a recipient artery [eg, external carotid artery] when performed in...
Wedge Excision with Reconstruction
December 17, 2020 Question: My physician did a full thickness wedge excision with an Estlander flap of the right upper lip with reconstruction utilizing a cheek flap, adjacent tissue transfer. The defect measures 27 sq. cm. The physician used a mucosal graft from the wedge excised from the lip with reconstruction of the vermillion of...
Documenting Family History for New Patient Visits
December 17, 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 not be accurate as we all have a family...
Stent and Embolization Coil Used in Same Session
December 17, 2020 Question: The surgeon used a stent and then inserted an embolization coil for an aneurysm. Are both billable? Answer: If the stent is placed to provide a latticework for deployment of the embolism coil, then no. You would just bill for the embolization. If the stent itself is the sole definitive procedure...
Modifier 78 or Modifier 79 Which Do I Use?
December 3, 2020 Question: My physician placed a permanent neurostimulator via laminectomy 6 days after the trial neurostimulator. I know I need to append a modifier to CPT code 63655 but do I use Modifier 78 or 79? Answer: You would not use either one. You would use Modifier 58 which is a staged or...
Coding 23395 for Pectoralis Muscle Repair
December 3, 2020 Question: Someone told us to bill 23395 for repairing the pectoralis muscle after removing breast implants. Here’s the common scenario: Removal of old bilateral breast implants with capsulectomies Repair of pectoralis muscle with re-attachment to chest wall Creation of pre-pectoral pocket with acellular dermal matrix Placement of bilateral breast implants for reconstruction...