April 29, 2021 Question: I am a pain management specialist. I have a patient who was referred to my office who has dementia and was unable to provide her medical history. The patient’s granddaughter was able to provide the patient’s medical history to me as the patient was confused and unable to provide this information....
April 15, 2021 Question: We are confused about the difference between modifier 52 and 53. What is the difference? Answer: Modifier 52 Reduced Services is used when the procedure or surgery is partially reduced or eliminated by the physician. This is used when a procedure has an existing CPT code, but not all of the...
April 1, 2021 Question: One of our physician assistants’ saw one of our established Medicare in the emergency room for increasing pain in the area being treated by the physician. The physician assistant made no changes to the plan of care established by the physician. Our physician assistant submitted this as an incident to service...
March 18, 2021 Question: My physicians have decided they would prefer to continue to use the E/M 1995/1997 guidelines for office visits instead of the new 2021 guidelines. Do we have a choice? Can we continue to use these guidelines? Answer: The new guidelines apply to office or other outpatient services 99202-99215 and are based...
March 4, 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 18, 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...
February 4, 2021 Question: My doctor reported 62323 for a steroid injection in the lumbar region in which he used imaging guidance. But he coded 62323, 62323-59 and 62323-59. I asked him why he was reporting this code three times and he indicated he had to make three attempts to get into the space so...
January 21, 2021 Question: I did a left intraarticular steroid injection in the ASC. I used fluoroscopic guidance. Can I report the Fluoro separately or is it included in the procedure code I used 20610? Answer: Yes, you can report fluoroscopic guidance with CPT code 20610. In the ASC make sure you report 77002-26. Modifier...
December 17, 2020 Question: We had a patient who came in for management of chronic right hip pain. I am new to pain management coding and not sure what diagnosis code to use. Can you help? Answer: Certainly. First based on the ICD-10-CM Official Guidelines for Coding and Reporting the first listed diagnosis code is...
December 3, 2020 Question: My physician placed a permanent neurostimulator via laminectomy 6 days after the trial neurostimulator. I know I need to append a modifier to CPT code 63655 but do I use Modifier 78 or 79? Answer: You would not use either one. You would use Modifier 58 which is a staged or...
