Category: Orthopaedics

Bone Cyst Tibia and Fibula
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Bone Cyst Tibia and Fibula

May 13, 2021 Question: Our surgeon documented an excision and curettage of a bone cyst from the tibia and the fibula near the ankle joint. I am looking at CPT code 27635 and wondering if this is the correct code and if I report it once or twice. Answer: CPT code 27635 (Excision or curettage...

Separate Procedure Billing
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Separate Procedure Billing

April 29, 2021 Question: I am new to coding and have a question. I remember studying about “separate procedures” and have my first operative note that includes a code that has this in the code definition. The surgeon performed a diagnostic arthroscopy (CPT code 29870) and confirmed the meniscal tear prior to proceeding with the...

2021 E/M Coding Guidelines: Time for Teaching Physician Services
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2021 E/M Coding Guidelines: Time for Teaching Physician Services

April 15, 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! CMS reimburses for the services of the attending physician, not the resident in training. Only the time of teaching physician would...

Medication Documentation
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Medication Documentation

March 18, 2021 Question: We are switching to a new EHR system. We have not always had great compliance with our providers documenting what we feel needs to be documented so we want to do it right. Are you able to advise what should be included in the medical record when the provider administers medications,...

Bone Filler Allograft
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Bone Filler Allograft

March 4, 2021 Question: We have a surgeon who performed an ORIF of an open tibia fracture and placed bone filler allograft in an area where the surgeon felt there was a small bone void. Is this work considered bundled or not? Neither the surgeon or I think it is billable but thought we should...

Injection of Blood to a Tendon
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Injection of Blood to a Tendon

February 18, 2021 Question: Our orthopaedic sports medicine physician recently injected blood at a tendon insertion site for treatment of tendonitis. The staff drew the blood from the antecubital fossa and gave the syringe to the surgeon. The surgeon said it is not “PRP” as he did not centrifuge the blood and create a concentrate...

‘Incident To’ Services
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‘Incident To’ Services

February 4, 2021 Question: One of our physician assistants’ saw one of our established Medicare in the emergency room for increasing pain in the area being treated by the physician. The physician assistant made no changes to the plan of care established by the physician. Our physician assistant submitted this as an incident to service...

New 2021 E/M Coding Guidelines
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New 2021 E/M Coding Guidelines

January 21, 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...

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