Category: CC-Otolaryngology

Laceration and Fracture Repair
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Laceration and Fracture Repair

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...

Does Type of Scope – Rigid or Flexible – Matter for Coding?
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Does Type of Scope – Rigid or Flexible – Matter for Coding?

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...

Cerumen Removal
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Cerumen Removal

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...

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

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...

Procedure with Spine Surgeon
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Procedure with Spine Surgeon

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...

New 2021 E/M Coding Guidelines
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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...

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