March 4, 2021 Question: We do a lot of hand surgery and have an x-ray machine in the office. This has made me confused about how to count the data for the neurosurgeon’s E/M code. Please help. Answer: Good question and let’s simplify things. The AMA specifically states there should be “no incentive”, related to...
February 18, 2021 Question: Would bilateral large breasts, on a patient that we are recommending breast reduction, count as 2 problems in the new E/M guidelines for office visits? Answer: No because these two problems will have the same concurrent treatment (breast reduction). Therefore, it counts as 1 problem. *This response is based on the...
February 4, 2021 Question: I’m confused about the Data component for the new office visit guidelines. What do I get credit for when a patient brings in her mammogram report? Answer: Good question. Assuming you (or your same specialty partner) did not order or bill for the mammogram, you would receive Category 1 Data credit...
January 21, 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...
December 17, 2020 Question: I heard that the E/M code guidelines are changing in 2021. Will this apply to all E/M codes? Answer: Good question. The 2021 changes will NOT apply to all E/M codes. The 2021 changes apply only to the new patient, 9920x, and established patient, 9921x, categories of codes. That means you...
December 3, 2020 Question: Someone told us to bill 23395 for repairing the pectoralis muscle after removing breast implants. Here’s the common scenario: Removal of old bilateral breast implants with capsulectomies Repair of pectoralis muscle with re-attachment to chest wall Creation of pre-pectoral pocket with acellular dermal matrix Placement of bilateral breast implants for reconstruction...
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’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...
October 15, 2020 Question: Our patient had full thickness burn of foot and has been having serial debridements to the bone 25x17cm. Patient returned to operating room for another debridement down to the bone then reconstruction of foot with a muscle flap. For the debridements prior to flap closure, is it appropriate to code 11044...
October 1, 2020 Question: The new guidelines that are coming out in 2021 for all types of E/M services, right? Answer: No. The new guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the current guidelines for all other E/M services, even consultations in the office. Learn more about the...
