Category: General Surgery

Skin Biopsy Codes
Post

Skin Biopsy Codes

December 5, 2019 Question: What happened to the skin biopsy codes?  I submitted a claim for 11101 (skin biopsy) and +11101 (additional lesion) and it was denied for “invalid code.” Answer: CPT deleted CPT codes 11100 and +11101, effective 1/1/19, and replaced them with the follow six new codes: 11102 Tangential biopsy of skin (eg,...

Use of a Scribe
Post

Use of a Scribe

November 14, 2019 Question: We are hiring a scribe for the doctor because it will help improve his documentation.  Is there anything we need to know about how to document this? Answer: Yes, absolutely. This situation should be clearly delineated so a third party reviewer can identify the provider who performed the service, and the...

How do you define “No Qualified Resident Available”?
Post

How do you define “No Qualified Resident Available”?

October 31, 2019 Question: Our physicians utilize residents during surgery but we have a discrepancy in what is considered a “Qualified Resident”. Some physicians consider a resident qualified to assist day 1 of their residency rotation, while others consider only 4th and 5th year residents as qualified to assist. Can you guide us to documentation...

Coding for FAST Exams
Post

Coding for FAST Exams

October 3, 2019 Question: I was told I cannot bill for FAST exams done in the ED for a trauma patient, if permanent recordings of the images are not retained. Is that correct? Answer: Yes. All diagnostic ultrasounds require 1) a separate interruption of the structures visualized and the findings in each and 2) a...

Coding for Percutaneous Tracheostomy
Post

Coding for Percutaneous Tracheostomy

September 19, 2019 Question: What code is used for percutaneous tracheostomy? Answer: Code 31600 is reported for “percutaneous” tracheostomy. This procedure is performed with a small incision and some direct visualization of the structures with or without a bronchoscope. The bronchoscope, used as a light source and to remove blood and secretions, is NOT separately...

Coding for REBOA
Post

Coding for REBOA

September 5, 2019 Question: What is REBOA and how is it coded? Answer: REBOA is used in trauma for patients that are rapidly bleeding from injuries to the chest, abdomen or pelvis. A flexible catheter is placed in the femoral artery, advanced to the aorta and a balloon is inflated at its tip. This stops...

Code +15777 for placement of a non-biologic implant. Is this the correct code?
Post

Code +15777 for placement of a non-biologic implant. Is this the correct code?

August 22, 2019 Question: I placed a non-biological implant for abdominal soft tissue reinforcement. Can this be coded as +15777? Answer: No. Code +15777 is reported specifically for a biological implant for soft tissue reinforcement implant in breast or trunk only. Code +0437T, a Category III code, is reported for implantation of a nonbiologic or...

Reporting a Cholecystectomy and an Umbilical Hernia at the Same Operative Session
Post

Reporting a Cholecystectomy and an Umbilical Hernia at the Same Operative Session

August 8, 2019 Question: If a patient undergoes an open cholecystectomy and has a reducible umbilical hernia repaired during the same operative session, through separate incisions, can both be reported? Answer: Yes, if both procedures were performed through separate incisions both may be reported. Conversely, if both were repaired through the same incision, only the...

Reporting a Cholecystectomy with a Cholangiogram
Post

Reporting a Cholecystectomy with a Cholangiogram

July 25, 2019 Question: If a cholangiogram was performed by the surgeon during a cholecystectomy, but the radiologist interprets it, is 47563, Laparoscopy, surgical; cholecystectomy with cholangiography still appropriate? Answer: Yes, the codes “with cholangiogram” are valued for intraoperative physician work, not the interpretation. *This response is based on the best information available as of...

Sign up for KZAlertsSign up for KZAlerts

Coding Coaches