March 4, 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...
Category: CC-Physiatry/Pain
Documenting Family History for New Patient Visits
February 18, 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...
Billing an Injection for Failed Attempts
February 4, 2021 Question: My doctor reported 62323 for a steroid injection in the lumbar region in which he used imaging guidance. But he coded 62323, 62323-59 and 62323-59. I asked him why he was reporting this code three times and he indicated he had to make three attempts to get into the space so...
Can I Bill for Fluoroscopy?
January 21, 2021 Question: I did a left intraarticular steroid injection in the ASC. I used fluoroscopic guidance. Can I report the Fluoro separately or is it included in the procedure code I used 20610? Answer: Yes, you can report fluoroscopic guidance with CPT code 20610. In the ASC make sure you report 77002-26. Modifier...
Need Help with a Diagnosis Code
December 17, 2020 Question: We had a patient who came in for management of chronic right hip pain. I am new to pain management coding and not sure what diagnosis code to use. Can you help? Answer: Certainly. First based on the ICD-10-CM Official Guidelines for Coding and Reporting the first listed diagnosis code is...
Modifier 78 or Modifier 79 Which Do I Use?
December 3, 2020 Question: My physician placed a permanent neurostimulator via laminectomy 6 days after the trial neurostimulator. I know I need to append a modifier to CPT code 63655 but do I use Modifier 78 or 79? Answer: You would not use either one. You would use Modifier 58 which is a staged or...
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...
New Evaluation and Management Guidelines for 2021 for Office Visits
October 29, 2020 Question: I work with a pain management physician and we see just a few Medicare patients. The physician believes the revised 2021 E/M guidelines will not impact our office practice because of our low Medicare volume. Is this correct? Answer: We are so happy you asked this question. This is not correct,...
Documenting Family History for New Patient Visits
October 15, 2020 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 be false as we all have a family history....
Genicular Nerve Destruction
October 1, 2020 Question: My doctor did a destruction of the superolateral and superomedial genicular nerve. Is there a CPT code for this procedure and can I report imaging guidance? Answer: You would report 64624-52 (reduced services). The code includes all of the following branches: superolateral, superomedial, and inferomedial. CPT directs that if all 3...