Category: Otolaryngology

Cerumen Removal
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Cerumen Removal

April 29, 2021 Question: If someone comes in for ear cleaning do you bill 69210 only or can you also bill an E/M code with modifier 25 and 69210? Answer: If the purpose of the encounter is for cerumen removal, as your scenario describes, then you would code only the cerumen removal (e.g., 69210).  Have...

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions
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Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 15, 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...

Procedure with Spine Surgeon
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Procedure with Spine Surgeon

March 4, 2021 Question: I was asked, by a new spine surgeon in town, to do the cervical approach for an anterior cervical decompression and fusion.  Do I use a regular neck dissection code such as 38724? Answer: Oh no, 38724 is for a modified radical neck dissection requiring removal of lymph nodes.  The cervical...

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

February 18, 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...

Significant Undermining of Free Flap Donor Site
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Significant Undermining of Free Flap Donor Site

January 21, 2021 Question: My doctor documents “significant undermining” to the free flap donor site (radial forearm) for an advancement flap. Can I also code an adjacent tissue transfer code such as 14060 for the closure? Answer: Actually, undermining is not considered an adjacent tissue transfer code (14xxx). CPT guidelines require a secondary defect to...

Carotid Artery Exploration with Free Flap to Oral Cavity
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Carotid Artery Exploration with Free Flap to Oral Cavity

December 17, 2020 Question: Can we report 35701 for the carotid vessel exploration in the recipient site when doing a fibula free flap (20969)? Answer: No, this activity is included in the free flap code. CPT specifically states not to 35701 to explore and identify a recipient artery [eg, external carotid artery] when performed in...

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