September 16, 2021 Question: If a code does not specify whether the procedure described is laparoscopic or open, is it acceptable to use it if the procedure was performed laparoscopically? Answer: No. Laparoscopic codes will always have the term “laparoscopic” in the code description. If there is no laparoscopic code for a procedure you performed...
September 2, 2021 Question: How do I report placement of a mesh implant in the abdomen that is not a biological implant and not for an open incisional hernia? Answer: Placement of a non-biological implant in the abdomen is reported with code +0437T Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of...
August 19, 2021 Question: I’ve been dictating CPT and ICD-10-CM codes in my procedure note so that my coder knows what to bill. Recently, we had an insurance company call us out because the codes we billed were not the same as the codes in the procedure note. Now I am not sure what to...
August 5, 2021 Question: Can you give guidance on CPT 15860 as it pertains to colorectal surgery? My surgeons have been using this code when they use the isocyanine green fluorescence imaging either with the robot (Firefly) or open (SpyPhi). They are saying this code is relevant because they are assessing vascular flow in a...
July 22, 2021 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,...
July 8, 2021 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...
June 24, 2021 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...
June 10, 2021 Question: Can you code a PTH (blood draw), during a parathyroidectomy? Answer: Monitoring the Parathyroid hormone (PTH), including the blood draw, is included in the parathyroidectomy and not separately reported. *This response is based on the best information available as of 6/10/21.
May 27, 2021 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...
May 13, 2021 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...
