June 30, 2022 Question: I am new in Dermatology coding and am currently coding for a Mohs surgeon. I was instructed that if the patient comes in and does not have a confirmed malignancy based on a pathology report and the physician does a biopsy to confirm the malignancy prior to Mohs surgery we can...
June 2, 2022 Question: I am trying to code an I&D of a pilonidal cyst. CPT 10080 is simple and 10081 is complicated. How to do I know which code to choose? Answer: Great question, you would report CPT 10081 (complicated) if the procedure requires marsupialization, approximation of the wound’s edges, and/or primary closure. *This...
May 5, 2022 Question: When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on if the condition is considered a chronic or acute condition? Answer: The AMA defines chronic as: A problem with an expected duration of at least...
April 7, 2022 Question: One of our dermatologists saw a patient the first time in our office. We billed 99204. The insurance carried denied the service. I contacted the insurance carrier and was told that the patient was an established patient to the practice and should be reported as an established patient. The patient did...
March 24, 2022 Question: If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate? Answer: No, sorry, unfortunately it does not work that way. The problems are no additive or cumulative. One stable chronic illness and one acute uncomplicated...
March 10, 2022 Question: I heard that Medicare patients don’t have to pay their deductible or coinsurance if they have a telemedicine visit. Is this true? Answer: Medicare is not waiving deductibles or co-insurance. However, they are allowing providers to do so at their discretion without penalty for telemedicine visits. This means the provider will...
February 24, 2022 Question: We are using the 2021 E/M guidelines in the office and in most cases base the level of service on medical decision making. If I have a patient with a chronic condition that is stable who also has diabetes in which the Internist (nor our specialty) is managing, can I assume...
February 10, 2022 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 record...
January 27, 2022 Question: We live in a northern state and frequently have patients who travel to warmer clients during the winter. Are you able to directly me to information on state licensure requirements for Telehealth services? Answer: Yes, you will now find this list on the KZA Telehealth Solution site https://www.karenzupko.com/KZA-telehealth-solution-center. Look for the...
December 30, 2021 Question: I heard that a medical assistant who enters the patient’s medications into the electronic health record must be certified. Is this true? Answer: Actually, Medicare requires the MA to be certified to perform order entry. They do not have to be certified to enter patient information such as vital signs or...
