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...
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...
April 1, 2021 Question: A new patient presents with a CD of an MRI that was performed at an outside institution and was read by the radiologist. There was no report with the CD. If one of my physicians reads the MRI can we bill for the second reading? Answer: No, reading the MRI that...
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,...
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...
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...
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...
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...
December 17, 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 not be accurate as we all have a family...
December 3, 2020 Question: Our surgeon performed a reconstruction of a patella dislocation and also did an arthrotomy of the knee with a lateral retinacular release. Our surgeon wants to report 27420 and 27425. When I look at the NCCI edits, I see there is an edit between the two codes. Am I allowed to...
