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...
September 17, 2020 Question: I work with an ENT and we don’t see many Medicare patients. The ENT believes the revised 2021 E/M guidelines will not impact our office practice because of our low Medicare volume. Is this correct? Answer: This is not correct! The revised documentation requirements are from CPT – the coding rule....
September 3, 2020 Question: I sent a patient out to the hospital for a CT scan and the patient brought in the actual images and the radiologist’s report for me to review. Can I charge 76140 (Consultation on X-ray examination made elsewhere, written report) when I personally interpret those images and write my own report?...
August 20, 2020 Question: My physician is utilizing an open laceration on the patient’s chin for open reduction of a mandibular symphysis fracture and he wants to also charge for a complex laceration repair for that laceration. Is this billable or is it part of the ORIF code? Answer: If the fracture is repaired through...
August 6, 2020 Question: Our coder recently attended one of your coding courses and her takeaway was that it was better to bill cerumen removal using an E/M code rather than 69210. Do you remember that discussion? Do you agree? Answer: No – good grief! This is an example of “people hear what they want...
July 23, 2020 Question: When I do an endoscopic septoplasty would I report both 31231 (nasal endoscopy) and 30520 (septoplasty)? Answer: We do not recommend reporting both codes. CPT says CPT 31231 (nasal endoscopy) denotes a “separate diagnostic procedure”. As such, it is not separately reported if any nasal/sinus definitive procedure (such as a septoplasty)...
July 9, 2020 Question: I took out 3 deep cervical nodes for biopsy on the left side. Can I bill 38510 x 3? Answer: No – you’d report 38510 once for any number of nodes removed from the same incision. *This response is based on the best information available as of 07/09/20.
