December 30, 2021 Question: I am trying to find the diagnosis code for vertebrogenic low back pain. Can you help? Answer: There is a new code that went into effect October 1, 2021, for Vertebrogenic low back pain M54.51. This new code distinguishes vertebrogenic low back pain for non-specific causes of back pain. *This response...
December 16, 2021 Question: We are using the 2021 E/M guidelines in the office and in most cases base the level of service on medical decision making. If I have a patient with a chronic condition that is stable who also has diabetes in which the Internist (nor our specialty) is managing, can I assume...
December 2, 2021 Question: We are hiring a scribe for the doctor because it will help improve his documentation. Is there anything we need to know about how to document this? Answer: Yes, absolutely. This situation should be clearly delineated so a third-party reviewer can identify the provider who performed the service, and the record...
November 11, 2021 Question: We live in a northern state and frequently have patients who travel to warmer clients during the winter. Are you able to directly me to information on state licensure requirements for Telehealth services? Answer: Yes, you will now find this list on the KZA Telehealth Solution site. Look for the tab...
October 28, 2021 Question: I heard that a medical assistant who enters the patient’s medications into the electronic health record must be certified. Is this true? Answer: Actually, Medicare requires the MA to be certified to perform order entry. They do not have to be certified to enter patient information such as vital signs or...
October 14, 2021 Question: I’ve been dictating CPT and ICD-10-CM codes in my procedure note so that my coder knows what to bill. Recently, we had an insurance company call us out because the codes we billed were not the same as the codes in the procedure note. Now I am not sure what to...
September 30, 2021 Question: I was told to use 0230T for a tranforaminal epidural injection (S1)with ultrasound. I sent to claim to Medicare in March 2021 and the claims was denied as an invalid code? Is there a new CPT code for this procedure? Answer: Code 0230T was deleted in 2921 and beginning January 2021...
September 16, 2021 Question: A patient with multiple sclerosis came into our pain clinic with spasms to the left and right upper arms. The physician injected the following muscles using EMG guidance; Right upper limb; right biceps, pronator teres, brachioradialis, first dorsal interosseous, and extensor carpi ulnaris and left upper limb, right biceps and brachioradialis....
September 2, 2021 Question: My doctor did a regional thoracic nerve block. He performed three injections at three intercostals levels. How do I code that? Answer: You would report 64420 (Injection, agent (s) and /or steroid, intercostal nerve, single level) and 64421 x 2 for the two additional level. Each additional level is reported with...
August 19, 2021 Question: One of my pain management physicians performed a trigger point into the 1 muscle and the documentation says dry needle technique. Do I code this using CPT code 20552? Answer: No, you would not report 20550 for dry needling. Prior to 2020, the service would be reported with the unlisted code...
