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...
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...
April 1, 2021 Question: Would bilateral recurrent acute otitis media, on a patient that will need tympanostomy tubes, count as 2 problems in the new E/M guidelines for office visits? Answer: No because these two problems will have the same concurrent treatment (tympanostomy tubes). Therefore, it counts as 1 problem. *This response is based on...
March 18, 2021 Question: We have an in-house CT which has made me confused about how to count the data for the my ENT’s E/M code. Please help. Answer: Good question and let’s simplify things. The AMA specifically states there should be “no incentive”, related to E/M coding, to the physician for ordering tests. So...
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...
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...
February 4, 2021 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...
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...
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...
December 3, 2020 Question: I did a right anterolateral thigh free flap and had to close the right thigh wound (4 x 8 cm) with undermining in either direction to close the wound without any significant tension. Can I also code a complex repair (13100, +13101) with the free flap code? Answer: Bringing the wound...
