Category: Otolaryngology

Tracheostomy with Glossectomy
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Tracheostomy with Glossectomy

July 22, 2021 Question: We billed 31600 for a tracheostomy along with 41140 (total glossectomy). CPT 31600 was denied. How can we appeal? Answer: Good question, however, the denial was appropriate.  CPT guidelines say that a tracheostomy is included in the glossectomy codes 41140 – 41155 as these procedures would not be performed without a...

CPT 62165 with 30140, 31254
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CPT 62165 with 30140, 31254

July 8, 2021 Question: Are CPT 30140 (submucous resection inferior turbinate) and 31254 (endoscopic anterior ethmoidectomy) bundled with code 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach)? I checked Medicare and there are no CCI edits so that seems that I can bill these codes together. The diagnosis code I billed...

Laceration and Fracture Repair
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Laceration and Fracture Repair

June 10, 2021 Question: My physician is utilizing an open laceration on the patients chin for open reduction of a mandibular symphysis fracture. He wants to also charge for complex laceration repair for that laceration. Is this billable or is it part of the ORIF code? Answer: If the fracture is repaired through the laceration...

Does Type of Scope – Rigid or Flexible – Matter for Coding?
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Does Type of Scope – Rigid or Flexible – Matter for Coding?

My 27, 2021 Question: Does 31231 (nasal endoscopy) have to be done with a rigid scope? Answer: The CPT descriptor for 31231 is: Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure). Notice it does not specify whether the scope must be rigid or flexible. That said, CPT makes it clear that the anatomic structures examined...

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...

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