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...
November 12, 2020 Question: I heard that the E/M code guidelines are changing in 2021. Will this apply to all E/M codes? Answer: Good question. The 2021 changes will NOT apply to all E/M codes. The 2021 changes apply only to the new patient, 9920x, and established patient, 9921x, categories of codes. That means you...
October 29, 2020 Question: We placed an ICP monitor on the left side of the cranium and a right ventriculostomy, both using the twist drill. We know to use CPT 61107 but wondered about using modifier 50 (bilateral procedure). Thoughts? Answer: Medicare does not recognize modifier 50 on 61107, though some payors might or may...
October 15, 2020 Question: I did an emergency craniectomy on a stroke patient 4 months ago. It is now time to reconstruct the defect and I’ll be doing that by placing some mesh and screws with Methyl methacrylate. Should I be using the 62140/62141 code series? Answer: Actually, CPT considers what you are doing to...
October 1, 2020 Question: How do I code for repair of wound dehiscence with deep abscess status post ACDF (anterior cervical discectomy, decompression and fusion)? I looked at 22010 but that’s for a posterior procedure. Answer: Take a look at 21501 (Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax) to...
September 17, 2020 Question: I just signed up for your 2021 E/M webinar – I’m so excited! Will these changes apply to inpatient codes too? Answer: Great – I look forward seeing you! At this time, the changes are only for new patient and established patient codes – office services. Learn more from Kim Pollock...
