July 11, 2019 Question: What’s the best way to do the diagnosis coding for postop visits? I mean, does it really matter since we aren’t billing for a visit? Answer: The ICD-10-CM guidelines for postop/aftercare include the following: If the original diagnosis is trauma (eg, using an S diagnosis code) or a code that requires...
June 20, 2019 Question: Can I bill for taking the patient back to the OR to explore and repair post-op hemorrhage on day 3 post-op? I heard that all complications are included in the payment of the original surgery. Answer: Yes, you may bill for this. CPT and Medicare agree that taking the patient back...
June 6, 2019 Question: I’ve been dictating CPT codes in the operative note so that my coder knows what to bill. Recently, we had an insurance company call us out because the codes we billed were not the same as the codes in the operative note. Now I am not sure what to do. What...
May 23, 2019 Question: My work RVUs are down this year. I do a lot of inferior turbinate submucous resection surgery and I code 30140 (Submucous resection inferior turbinate, partial or complete, any method). I noticed that the wRVUs for 30140 are now 3.00 and last year they were 3.57. This is a big hit...
May 9, 2019 Question: When would I ever use G0268 for cerumen removal vs 69210? Answer: G0268 is a HCPCS II code for “Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing” while CPT code 69210 says “Removal impacted cerumen requiring instrumentation, unilateral.” Historically, G0268...
April 25, 2019 Question: We are receiving denials for 31237, performed right after endoscopic sinus surgery, stating we did not get prior approval and there was no documentation stating the need for the debridement in my office notes. Have you heard of this? Answer: Yes. Some payors require precertification for this surgical procedure even when performed...
April 11, 2019 Question: I recently attended a coding course you taught and learned a lot – thank you! I will say though that I am slightly confused by one thing you said… a history in the op note? I have never put any history in an op note. Where do you put any kind...
March 28, 2019 Question: My billing service is waiting for the pathology report and assigning the diagnosis and procedure code for benign or malignant skin lesion removal. This I completely understand. However, they are asking me to amend my procedure note accordingly once the pathology report is back. This is a lot of extra work...
March 14, 2019 Question: If I do a cosmetic rhinoplasty and a functional septoplasty on a patient, should I document both procedures on the same operative note? Or should I document a separate operative note for each procedure? Answer: Good question! In KZA’s experience, it is best to document one operative note for all procedures...
February 28, 2019 Question: I have a question on billing for allergy testing. All this time, and for any patient getting allergy testing, ICD-10 code J30.1 (Allergic Rhinitis due to pollen) has been the diagnosis code we are using. At the recent KZA workshop ICD-10 code Z01.82 (encounter for allergy testing) could also be used, but...
