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...
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...
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...
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...
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...
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...
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...
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...
