November 12, 2020 Question: My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me. Answer: You are wise to ask because that’s not exactly true. It is correct that the History will no longer be...
October 29, 2020 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...
October 15, 2020 Question: Our patient had full thickness burn of foot and has been having serial debridements to the bone 25x17cm. Patient returned to operating room for another debridement down to the bone then reconstruction of foot with a muscle flap. For the debridements prior to flap closure, is it appropriate to code 11044...
October 1, 2020 Question: The new guidelines that are coming out in 2021 for all types of E/M services, right? Answer: No. The new guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the current guidelines for all other E/M services, even consultations in the office. Learn more about the...
September 17, 2020 Question: I work with a plastic surgeon and we don’t see many Medicare patients. The plastic surgeon 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...
September 3, 2020 Question: At the time of the second stage tissue expander exchange, my plastic surgeon wants to bill 19380 for either liposuction, removing excess scar tissue, removing redundant excess skin or removing adipose tissue. “The lateral aspect of the mastectomy scar is excised along with redundant skin and subcutaneous tissue to revise the...
August 20, 2020 Question: My Plastic Surgeon is asking about breast reconstruction coding. We use either S2068 and or 19364 depending on the payor. Will these codes allow a co-surgeon (modifier 62) and assistant surgeon (modifier 80) for a total of 3 billed surgeons? When asking providers I can’t seem to get a clear answer....
August 6, 2020 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...
July 23, 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...
July 9, 2020 Question: I did a right anterolateral thigh free flap and had to close the right thigh wound (4 x 8 cm) with undermining of additional 3 cm 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?...
