Category: Otolaryngology

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...

Bjork Flap Tracheostomy
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Bjork Flap Tracheostomy

October 15, 2020 Question: What would the correct CPT code be for a tracheostomy performed using a Bjork flap? I see some people stating it should be 31610. However, a Bjork flap is technically not a skin flap. I thought CPT 31610 was more for when a permanent stoma is created. Answer: CPT 31600 is...

Are Pre-Op Visits Billable?
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Are Pre-Op Visits Billable?

October 1, 2020 Question: For patients that are having surgery that day, I’ve been doing pre-op visits that morning (coming in earlier), and not doing a preop visit in clinic the week before surgery. Can I bill a follow up visit for the meeting/note (H&P) that occurs the morning of surgery? Answer: No – a...

Evaluation and Management Codes 2021 – Do I Have to Use the Revised Guidelines?
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Evaluation and Management Codes 2021 – Do I Have to Use the Revised Guidelines?

September 17, 2020 Question: I work with an ENT and we don’t see many Medicare patients. The ENT believes the revised 2021 E/M guidelines will not impact our office practice because of our low Medicare volume. Is this correct? Answer: This is not correct! The revised documentation requirements are from CPT – the coding rule....

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