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...
Category: CC-Otolaryngology
New 2021 E/M Coding Guidelines
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...
Documenting Family History for New Patient Visits
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...
Significant Undermining of Free Flap Donor Site
January 21, 2021 Question: My doctor documents “significant undermining” to the free flap donor site (radial forearm) for an advancement flap. Can I also code an adjacent tissue transfer code such as 14060 for the closure? Answer: Actually, undermining is not considered an adjacent tissue transfer code (14xxx). CPT guidelines require a secondary defect to...
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...
Complex Closure of Free Flap Donor Site
December 3, 2020 Question: I did a right anterolateral thigh free flap and had to close the right thigh wound (4 x 8 cm) with undermining in either direction to close the wound without any significant tension. Can I also code a complex repair (13100, +13101) with the free flap code? Answer: Bringing the wound...
2021 Evaluation and Management Codes: Is a History Required?
November 12, 2020 Question: My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me. Answer: You are wise to ask because that’s not exactly true. It is correct that the History will no longer be...
Repair of a Semi-Circular Canal Dehiscence with Neurosurgery
October 29, 2020 Question: We are doing a combined case with the neurosurgeon and are not sure how to code it. The patient has a semi-circular canal dehiscence of the temporal bone. I am going to do the approach and the neurosurgeon will repair the defect with local bone. We will use mesh to reconstruct...
Bjork Flap Tracheostomy
October 15, 2020 Question: What would the correct CPT code be for a tracheostomy performed using a Bjork flap? I see some people stating it should be 31610. However, a Bjork flap is technically not a skin flap. I thought CPT 31610 was more for when a permanent stoma is created. Answer: CPT 31600 is...
Are Pre-Op Visits Billable?
October 1, 2020 Question: For patients that are having surgery that day, I’ve been doing pre-op visits that morning (coming in earlier), and not doing a preop visit in clinic the week before surgery. Can I bill a follow up visit for the meeting/note (H&P) that occurs the morning of surgery? Answer: No – a...