April 29, 2021 Question: I just finished my residency and am in an employed situation. In reviewing my end-of-month RVU reports, I’m seeing a lot of the codes I submitted are missing. I’m starting to wonder if I have been coding wrong or the hospital’s coders. Can we code for intrathecal morphine at the end...
April 15, 2021 Question: I’m still confused about the new E/M guidelines. Do these new guidelines apply to the consultation codes? Also, I have so many more questions, can you help me? Answer: Yes and yes! First, the new E/M guidelines do NOT apply to the office/outpatient consultation codes, 9924x. So you’ll continue to code...
April 1, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the AMA (3/24/21 webinar), you should only document one or the other to prevent potential audit confusion and risk. Document time if billing by time OR...
March 18, 2021 Question: Can I bill a wound debridement code such as 11043 when I debride an infected wound and take out a VNS battery? Answer: Don’t forget that the debridement codes, such as 11043, are for debriding open wounds that will stay open and heal by second intention. That’s not what you did....
March 4, 2021 Question: Would bilateral L4-L5 herniated discs count as 2 problems in the new E/M guidelines for office visits? Answer: No because these two problems are at the same spinal level and are treated with the same procedure (discectomy). Therefore, it counts as 1 problem. *This response is based on the best information...
February 18, 2021 Question: We have an MRI in house which has made me confused about how to count the data for the neurosurgeon’s E/M code. Please help. Answer: Good question and let’s simplify things. The AMA specifically states there should be “no incentive”, related to E/M coding, to the physician for ordering tests. So...
February 4, 2021 Question: In the new guidelines, how does Time affect billing for a teaching physician’s E/M service when the resident spends a great deal of time with the patient? Answer: Good question! Only the time of teaching physician would “count” in the scenario you describe. The new guidelines say that the time of...
January 21, 2021 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...
December 17, 2020 Question: The surgeon used a stent and then inserted an embolization coil for an aneurysm. Are both billable? Answer: If the stent is placed to provide a latticework for deployment of the embolism coil, then no. You would just bill for the embolization. If the stent itself is the sole definitive procedure...
December 3, 2020 Question: What’s the best way to code a retrosigmoid approach and removal of a meningioma at the cerebellopontine angle? Should I use 61519 or 61520? Answer: CPT 61520 (Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor) is more accurate since it better describes the location of the...
