June 10, 2021 Question: My physician is utilizing an open laceration on the patients chin for open reduction of a mandibular symphysis fracture. He wants to also charge for complex laceration repair for that laceration. Is this billable or is it part of the ORIF code? Answer: If the fracture is repaired through the laceration...
My 27, 2021 Question: Does 31231 (nasal endoscopy) have to be done with a rigid scope? Answer: The CPT descriptor for 31231 is: Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure). Notice it does not specify whether the scope must be rigid or flexible. That said, CPT makes it clear that the anatomic structures examined...
My 13, 2021 Question: A new patient had excessive dried blood and hematoma in the external ear canal. Under microscopy, the provider used an angled pick, alligator forceps and suction to remove the hematoma and dried blood debris. Is there an additional CPT that should be reported for the procedure? Answer: There is a not...
April 29, 2021 Question: If someone comes in for ear cleaning do you bill 69210 only or can you also bill an E/M code with modifier 25 and 69210? Answer: If the purpose of the encounter is for cerumen removal, as your scenario describes, then you would code only the cerumen removal (e.g., 69210). Have...
April 15, 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...
April 1, 2021 Question: Would bilateral recurrent acute otitis media, on a patient that will need tympanostomy tubes, count as 2 problems in the new E/M guidelines for office visits? Answer: No because these two problems will have the same concurrent treatment (tympanostomy tubes). Therefore, it counts as 1 problem. *This response is based on...
March 18, 2021 Question: We have an in-house CT which has made me confused about how to count the data for the my ENT’s E/M code. Please help. Answer: Good question and let’s simplify things. The AMA specifically states there should be “no incentive”, related to E/M coding, to the physician for ordering tests. So...
March 4, 2021 Question: I was asked, by a new spine surgeon in town, to do the cervical approach for an anterior cervical decompression and fusion. Do I use a regular neck dissection code such as 38724? Answer: Oh no, 38724 is for a modified radical neck dissection requiring removal of lymph nodes. The cervical...
February 18, 2021 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...
February 4, 2021 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...
