June 30, 2022 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...
June 16, 2022 Question: While performing a cholecystectomy a tear in the small bowel was made during extensive lysis of adhesions. Can repair of this injury be billed in addition to the cholecystectomy? It was unavoidable since it was the consequence of the extensive lysis required? Answer: Although the tear was unavoidable, the repair would...
June 2, 2022 Question: The surgeon did a robotic/laparoscopic cholecystectomy and cholangiogram with ICG 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...
May 19, 2022 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...
May 5, 2022 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...
April 21, 2022 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...
April 7, 2022 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 and is a common misconception. The revised documentation requirements come...
March 24, 2022 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...
March 10, 2022 Question: Can you bill for a wound vac on a surgical incision if the patient has a history of incision infections to help prevent this? Answer: The AMA published clarification on wound vac billing in the October 2021 CPT Assistant. Negative pressure wound therapy (97605-97606) is considered billable for both open and...
February 24, 2022 Question: My provider indicated that it took her an additional 80 minutes during a surgery to perform adhesiolysis. Is documentation of the time sufficient? Answer: Although time (specific minutes) should always be indicated in the operative note, the provider must also give the reason why the lysis took longer (what complicated this...
