December 17, 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...
Category: General Surgery
Billing for Reopening of Recent Laparotomy
December 3, 2020 Question: Our surgeon insists on billing for 49002 reopening of a recent laparotomy and a 44005 lysis of adhesions, since the case is complicated because the laparotomy was only 60 days ago. Can he bill for both in any circumstance? Answer: Although this was a reopening of a recent laparotomy, lysis of...
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...
Billing for Intestinal Tear During Enterostomy Closure
October 29, 2020 Question: While performing an enterostomy closure (44626) a tear in the small bowel was made during extensive lysis of adhesions. Can this be billed as a 44120, since it required surgical repair and couldn’t be avoided due to the severity of the lysis? Answer: Although the tear was from friable (fragile) tissue...
Billing for “Icy Green” Dye
October 15, 2020 Question: The surgeon did a robotic/laparoscopic cholecystectomy and cholangiogram with icy green and firefly identification of biliary anatomy. He billed a 47563. Can he can bill separately for the icy green and firefly dye? Answer: Billing for indocyanine (ICG) or Firefly TM fluorescence is bundled into 47563 laparoscopic cholecystectomy with cholangiogram and is not separately billable. *This...
Confusion About New 2021 E/M Guidelines
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. *This response is based...
Abdominal Fat Pad Core Biopsy
September 17, 2020 Question: We did an abdominal fat pad biopsy for primary cutaneous Amyloidosis. Would 49180 or 11104 be the appropriate code for this? Answer: 49180 is for a core sample within or behind the abdominal cavity. If the core biopsy is documented down to the subcutaneous fat pad only, this is coded as...
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...
2021 EM Guidelines: Only for Medicare?
August 20, 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...
Hartmann or Partial Colectomy
August 6, 2020 Question: My surgeon performed all the components of a Hartmann procedure 44143 but did not create a colostomy. Can we use 44143 with a -52 modifier? Answer: The correct code for this procedure would be 44140. Code 44140 is the base code for 44143 with the only difference being a skin level...