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Modifier 78 or Modifier 79 Which Do I Use?

Modifier 78 or Modifier 79 Which Do I Use?

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…
Coding 23395 for Pectoralis Muscle Repair

Coding 23395 for Pectoralis Muscle Repair

December 3, 2020 Question: Someone told us to bill 23395 for repairing the pectoralis muscle after removing breast implants. Here’s the common scenario: Removal of old bilateral breast implants with…
Stent vs. Embolization or Both

Stent vs. Embolization or Both

December 3, 2020 Question: If the surgeon uses a covered stent and performs an embolization on a patient with a pseudoaneurysm, can we bill for both the stent and removal…
Is a Lateral Retinacular Release Separately Billable?

Is a Lateral Retinacular Release Separately Billable?

December 3, 2020 Question: Our surgeon performed a reconstruction of a patella dislocation and also did an arthrotomy of the knee with a lateral retinacular release. Our surgeon wants to…
Complex Closure of Free Flap Donor Site

Complex Closure of Free Flap Donor Site

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…
Paring or Cutting

Paring or Cutting

December 3, 2020 Question: I am new to Dermatology coding and need some help. The previous coder told me for CPT 11055 (paring or cutting) that if more than one…
Billing for Reopening of Recent Laparotomy

Billing for Reopening of Recent Laparotomy

December 3, 2020 Question: Our surgeon insists on billing for 49002 reopening of a recent laparotomy and a 44005 lysis of adhesions, since the case is complicated because the laparotomy…
Removal of CP Angle Meningioma

Removal of CP Angle Meningioma

December 3, 2020 Question: What’s the best way to code a retrosigmoid approach and removal of a meningioma at the cerebellopontine angle? Should I use 61519 or 61520? Answer: CPT…
2021 Evaluation and Management Codes: Is a History Required?

2021 Evaluation and Management Codes: Is a History Required?

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…
2021 Evaluation and Management Codes: Is a History Required?

2021 Evaluation and Management Codes: Is a History Required?

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…
New 2021 Evaluation and Management Code Guidelines

New 2021 Evaluation and Management Code Guidelines

November 12, 2020 Question: I heard that the E/M code guidelines are changing in 2021.  Will this apply to all E/M codes? Answer: Good question. The 2021 changes will NOT…
New 2021 Evaluation and Management Code Guidelines

New 2021 Evaluation and Management Code Guidelines

November 12, 2020 Question: I heard that the E/M code guidelines are changing in 2021.  Will this apply to all E/M codes? Answer: Good question.  The 2021 changes will NOT…
2021 Evaluation and Management Codes: Is a History Required?

2021 Evaluation and Management Codes: Is a History Required?

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…
New 2021 Evaluation and Management Code Guidelines

New 2021 Evaluation and Management Code Guidelines

November 12, 2020 Question: I heard that the E/M code guidelines are changing in 2021.  Will this apply to all E/M codes? Answer: Good question.  The 2021 changes will NOT…
2021 Evaluation and Management Codes: Is a History Required?

2021 Evaluation and Management Codes: Is a History Required?

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…
New 2021 Evaluation and Management Code Guidelines

New 2021 Evaluation and Management Code Guidelines

November 12, 2020 Question: I heard that the E/M code guidelines are changing in 2021.  Will this apply to all E/M codes? Answer: Good question.  The 2021 changes will NOT…
Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

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.…
New Evaluation and Management Guidelines for 2021 for Office Visits

New Evaluation and Management Guidelines for 2021 for Office Visits

October 29, 2020 Question: I work with a pain management physician and we see just a few Medicare patients. The physician believes the revised 2021 E/M guidelines will not impact…
Dialysis Circuit Revision

Dialysis Circuit Revision

October 29, 2020 Question: My vascular surgeon performed a dialysis circuit open revision, and had to remove subcutaneous fat during the procedure. He said this was a more complex procedure…
SI Joint Injection Help

SI Joint Injection Help

October 29, 2020 Question: My physician performed an SI joint injection in the ASC under ultrasound guidance and wants to bill 27096 and 76942. Is this correct? The description of…
Repair of a Semi-Circular Canal Dehiscence with Neurosurgery

Repair of a Semi-Circular Canal Dehiscence with Neurosurgery

October 29, 2020 Question: We are doing a combined case with the neurosurgeon and are not sure how to code it. The patient has a semi-circular canal dehiscence of the…
Excision of Cyst

Excision of Cyst

October 29, 2020 Question: I need some help. The physician made an incision over a cyst was able to remove the contents in total or by piece meal. Would this…
Billing for Intestinal Tear During Enterostomy Closure

Billing for Intestinal Tear During Enterostomy Closure

October 29, 2020 Question: While performing an enterostomy closure (44626) a tear in the small bowel was made during extensive lysis of adhesions. Can this be billed as a 44120,…
ICP Monitor and EVD Placed on Both Sides

ICP Monitor and EVD Placed on Both Sides

October 29, 2020 Question: We placed an ICP monitor on the left side of the cranium and a right ventriculostomy, both using the twist drill. We know to use CPT…
Burn Debridements

Burn Debridements

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…
Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

October 15, 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.…
Bjork Flap Tracheostomy

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…
Billing Separately for Diagnostic Angiograms

Billing Separately for Diagnostic Angiograms

October 15, 2020 Question: Our surgeon performed an aortogram with run-off to bilateral lower extremities. He then performed interventions in the left SFA and the left peroneal arteries. My question…
Subacromial Decompression (29826)

Subacromial Decompression (29826)

October 15, 2020 Question: Our surgeon frequently documents in the procedure title that an arthroscopic subacromial decompression was performed.  We are billing 29826 and are receiving denials from one particular…
MOHS with an E/M Service

MOHS with an E/M Service

October 15, 2020 Question: A Medicare patient came in last week and my doctor did a biopsy on the chest and it came back malignant and meets the Medicare criteria…
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