Category: CC-Neurosurgery

TDA with ACDF
Post

TDA with ACDF

July 22, 2021 Question: My surgeon did an ACDF at C5-C6 and C6-C7 but also did an artificial disc (TDA) at C4-C5.  Can I bill for all three procedures? Answer: Yes, you may bill for different procedures performed at different spinal levels. You may need to append modifier 59 (distinct procedural services) to reflect the...

Non-Segmental vs Segmental Instrumentation
Post

Non-Segmental vs Segmental Instrumentation

July 8, 2021 Question: The provider listed one of the procedure statements as bilateral percutaneous L4-L5 segmental instrumentation placement along with the fusion and decompression procedures. In the body of the note he describes placing instrumentation on both sides for the L4-L5. We queried the provider asking for correction of listed procedure to non-segmental (22840). ...

Bilateral Sciatica
Post

Bilateral Sciatica

June 10, 2021 Question: What is the correct  ICD-10-CM for bilateral sciatica? My doctor tells me to use both M54.31 & M54.32 but this doesn’t seem right. Answer: There is not a diagnosis code for bilateral sciatica. You are correct to use M54.32 and M54.31 to report this condition. *This response is based on the...

Two-Level Kyphoplasty
Post

Two-Level Kyphoplasty

May 27, 2021 Question: When doing a T12 & L3 kyphoplasty, are the correct codes 22513 (thoracic) and 22514 (lumbar)? Answer: The correct codes are 22513 (thoracic) and +22515 (additional level) for your example. It is not accurate to report two stand-alone codes (22513 and 22514) for procedures performed at the same operative session. *This...

New E/M Guidelines: Confusion
Post

New E/M Guidelines: Confusion

April 15, 2021 Question: I’m still confused about the new E/M guidelines.  Do these new guidelines apply to the consultation codes? Also, I have so many more questions, can you help me? Answer: Yes and yes!  First, the new E/M guidelines do NOT apply to the office/outpatient consultation codes, 9924x. So you’ll continue to code...

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions
Post

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 1, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the AMA (3/24/21 webinar), you should only document one or the other to prevent potential audit confusion and risk. Document time if billing by time OR...

Sign up for KZAlertsSign up for KZAlerts

Coding Coaches