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...
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...
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...
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...
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...
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...
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: 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,...
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....
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...
