Category: <span>Coding Coach</span>

Evaluation and Management Codes 2021 – Do I Have to Use the Revised Guidelines?
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Evaluation and Management Codes 2021 – Do I Have to Use the Revised Guidelines?

September 3, 2020 Question: I work with a neurosurgeon and we don’t see many Medicare patients. The neurosurgeon 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....

Coding a Hand Assisted Laparoscopy
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Coding a Hand Assisted Laparoscopy

September 3, 2020 Question: The surgeon described the procedure as a ‘hand assisted laparoscopy”  He brought part of the bowel outside of the body for evaluation.  Does this convert the procedure to open? Answer: Mobilizing the bowel outside the body (extracorporeally) during a laparoscopic procedure does not convert the procedure to open,  it is still...

Transforaminal Injection
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Transforaminal Injection

September 3, 2020 Question: I am new to pain management coding and have a question. What is the correct way to bill for a transforaminal injection of L3-L4 and L4-5? He is injecting L3-L4 bilaterally and L3-L4 on one side. Can I report 64483 three times? Answer: No, you would report 64483 (first level) and...

2021 EM Guidelines: Only for Medicare?
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2021 EM Guidelines: Only for Medicare?

September 3, 2020 Question: I work with a surgeon and we see just a few Medicare patients. The surgeon 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, but it is a common misconception. The revised documentation requirements...

Tissue Expander Exchange with Breast Reconstruction Revision
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Tissue Expander Exchange with Breast Reconstruction Revision

September 3, 2020 Question: At the time of the second stage tissue expander exchange, my plastic surgeon wants to bill 19380 for either liposuction, removing excess scar tissue, removing redundant excess skin or removing adipose tissue. “The lateral aspect of the mastectomy scar is excised along with redundant skin and subcutaneous tissue to revise the...

Actinic Keratoses
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Actinic Keratoses

September 3 , 2020 Question: When using liquid nitrogen to for irritated actinic keratoses what CPT codes should I use? I have been using 17110 and my coder told me that was wrong. Answer: You should report 17000 for the first AK (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic...

SI Joint Injection Help
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SI Joint Injection Help

August 20, 2020 Question: My physician performed an SI joint injection in the ASC under ultrasound guidance and wants to bill 27096 and 76942. Is this correct? The description of the codes say imaging is included. Answer: If ultrasound is used instead of fluoroscopy, or CT, report a trigger point injection with 76942. Some payor...

Laceration and Fracture Repair
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Laceration and Fracture Repair

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...

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Coding Coaches