Category: CC-General Surgery

Skin Biopsy Codes
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Skin Biopsy Codes

July 22, 2021 Question: What happened to the skin biopsy codes? I submitted a claim for 11101 (skin biopsy) and +11101 (additional lesion) and it was denied for “invalid code.” Answer: CPT deleted CPT codes 11100 and +11101, effective 1/1/19, and replaced them with the follow six new codes: 11102 Tangential biopsy of skin (eg,...

Use of a Scribe
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Use of a Scribe

July 8, 2021 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...

How Do You Define “No Qualified Resident Available”?
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How Do You Define “No Qualified Resident Available”?

June 24, 2021 Question: Our physicians utilize residents during surgery but we have a discrepancy in what is considered a “Qualified Resident”. Some physicians consider a resident qualified to assist day 1 of their residency rotation, while others consider only 4th and 5th year residents as qualified to assist. Can you guide us to documentation...

Coding for FAST Exams
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Coding for FAST Exams

May 27, 2021 Question: I was told I cannot bill for FAST exams done in the ED for a trauma patient, if permanent recordings of the images are not retained. Is that correct? Answer: Yes. All diagnostic ultrasounds require 1) a separate interruption of the structures visualized and the findings in each and 2) a...

Coding for REBOA
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Coding for REBOA

May 13, 2021 Question: What is REBOA and how is it coded? Answer: REBOA is used in trauma for patients that are rapidly bleeding from injuries to the chest, abdomen or pelvis. A flexible catheter is placed in the femoral artery, advanced to the aorta and a balloon is inflated at its tip. This stops...

OOOPs. I Nicked a Vessel. Can I Bill for Repairing it?
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OOOPs. I Nicked a Vessel. Can I Bill for Repairing it?

April 29, 2021 Question: The surgeon accidentally nicked a vessel not involved in the bypass being performed, can he bill for repair of vessel since he had to repair it? Answer: Iatrogenic, intraoperative complications that are repaired at the same operative session are not separately reported. Since the vessel laceration was an iatrogenic injury, inadvertently...

Co-Surgeon or Assistant?
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Co-Surgeon or Assistant?

April 15, 2021 Question: A vascular surgeon is requested to come to the OR to repair a blood vessel that my surgeon inadvertently nicked during a colectomy. Is he a co-surgeon or assistant on the case? Answer: Neither. The vascular surgeon will report his work, repair of vessel, and you will report yours. *This response...

Modifier 58 vs. Modifier 78
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Modifier 58 vs. Modifier 78

March 18, 2021 Question: Do some insurance carriers want modifier 58 and others want 78?  What is the difference in these modifiers? Answer: Modifier 58 is used on a subsequent surgery when a planned (or staged) related procedure is performed within the global period of the first surgery. If possible, but not required, the surgeon...

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