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...
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...
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...
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...
July 23, 2020 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) must be indicated in the operative note, the provider must also give the reason why the lysis took longer (what complicated this part...
July 9, 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 be false as we all have a family history....
June 25, 2020 Question: Can I bill for different diagnosis codes for conditions/problems when seeing a patient in the hospital after surgery, but during the stay of a major surgery? Answer: It depends. You cannot bill for related issues or known complications that arise from the surgery, but you can bill for unrelated conditions/problems with...
June 11, 2020 Question: Instead of a colostomy as described in the laparoscopic CPT codes 44208 or the open code, 44146, my doctor does a diverting ileostomy. We have been billing the primary codes 44145 or 44207 and adding the ileostomy code, 44187 if laparoscopic or 44310 if open. Is that correct? Answer: Partial colectomy...
May 28, 2020 Question: Can we bill the 92242 for the indocyanine green injection intraoperatively, for example to assess perfusion after a colectomy or other abdominal procedure? Can we bill for the injection using 15860? Answer: No, this service is included in primary surgery and not separately reported. *This response is based on the best...
May 14, 2020 Question: Since we have to bring the patients back in for COVID testing and H&P for Joint Commission, can we bill for this visit even though it’s another pre-op visit? Answer: Yes, since the patient was rescheduled due to the pandemic and needs to be seen for a COVID swab prior to surgery,...
