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ER Visit Coding

ER Visit Coding

May 5, 2022 Question: What code do use when our pain doctor sees a patient in the emergency department for a consultation at the request of the ED physician? Our…
Spinal Wound Closure with Flaps

Spinal Wound Closure with Flaps

May 5, 2022 Question: One of our spine surgeons has asked me to help with an upcoming case. The patient is obese and has had multiple prior spine procedures. The…
LCDs and Vein Procedures: Should We Know About These?

LCDs and Vein Procedures: Should We Know About These?

May 5, 2022 Question: We have an office-based vein center and have heard that something called LCDs should be followed before a procedure is performed. We’re not sure what these…
Grafts/Implants

Grafts/Implants

May 5, 2022 Question: I know in years past from attending KZA/ AAOS workshops that the instructors taught that bone grafts (CPT code 20900 and 20902) were only reportable if…
Vocal Fold Augmentation Injections in the Office

Vocal Fold Augmentation Injections in the Office

May 5, 2022 Question: What code do I use for a vocal fold injection for augmentation in the office? Can I also bill for the injection material? Answer: Good questions!…
Acute Versus Chronic Conditions for Office E/M Services

Acute Versus Chronic Conditions for Office E/M Services

May 5, 2022 Question: When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on…
Abdominal Fat Pad Core Biopsy

Abdominal Fat Pad Core Biopsy

May 5, 2022 Question: We did an abdominal fat pad biopsy for primary cutaneous Amyloidosis. Would 49180 or 11104 be the appropriate code for this? Answer: 49180 is for a…
ER Visit Coding

ER Visit Coding

May 5, 2022 Question: What code do we charge for an ER visit when our physician was called to the ER by the ER doctor. The patient has Medicare. Answer:…
Gender Reassignment “Top” Surgery Coding

Gender Reassignment “Top” Surgery Coding

April 21, 2022 Question: We are having a debate on whether to use a mastectomy code or breast reduction code for “top” female-to-male procedures. What’s your advice? Answer: Unfortunately, we…
Inpatient E/M Coding

Inpatient E/M Coding

April 21, 2022 Question: I did an inpatient consultation and coded 99253 (non-Medicare). I did not need to follow the patient so I signed off. They asked me to re-consult…
Coding a Hand Assisted Laparoscopy

Coding a Hand Assisted Laparoscopy

April 21, 2022 Question: The surgeon described the procedure as a ‘hand assisted laparoscopy”. He brought part of the bowel outside of the body for evaluation. Does this convert the…
Cerebellopontine Angle Surgery

Cerebellopontine Angle Surgery

April 21, 2022 Question: I did a posterior fossa craniectomy for resection of a cerebellopontine angle tumor requiring the dura to be repaired with a synthetic graft and reconstruction of…
Intraoperative ICG Dye Angiography

Intraoperative ICG Dye Angiography

April 21, 2022 Question: Can we bill the 92242 for the indocyanine green injection intraoperatively, for example to assess perfusion after a procedure? Can we bill for the injection using…
Tendon Repair

Tendon Repair

April 21, 2022 Question: I am new to orthopaedic hand coding. I have a case where the surgeon repaired two flexor tendons in the finger. I am being told that…
Billing for a Neurostimulator Implant

Billing for a Neurostimulator Implant

April 7, 2022 Question: My physician billed implanted a neurostimulator into the sacral nerve for urinary incontinence. We billed CPT codes 64562 and 95972 for a Medicare patient. Medicare denied…
Level 5 Office E/M Code

Level 5 Office E/M Code

April 7, 2022 Question: I was told that if I recommend surgery then I can automatically bill 99205 or 99215. This seems too good to be true. Please advise. Answer:…
Wound Vac Billing

Wound Vac Billing

April 7, 2022 Question: I’m a general surgeon. Some of my team are reporting the negative pressure wound therapy codes 97605 and 97606 when applying wound vacs after closing at…
Prolotherapy

Prolotherapy

April 7, 2022 Question: Our sports medicine physician is planning to perform a Prolotherapy procedure on a patient who has tendinitis. The physician would like to know what CPT code…
Adjacent Tissue Transfer

Adjacent Tissue Transfer

April 7, 2022 Question: A few years ago I was at your coding workshop in Chicago – you were great, Kim! I remember discussing the adjacent tissue transfer or rearrangement…
New Patient Visit Denied, What Should I Do?

New Patient Visit Denied, What Should I Do?

April 7, 2022 Question: One of our dermatologists saw a patient the first time in our office. We billed 99204. The insurance carried denied the service. I contacted the insurance…
2021 EM Guidelines: Only for Medicare?

2021 EM Guidelines: Only for Medicare?

April 7, 2022 Question: I work with a surgeon and we see just a few Medicare patients. The surgeon believes the revised 2021 E/M guidelines will not impact our office…
PA Billing ED Consult

PA Billing ED Consult

April 7, 2022 Question: Can a PA bill a consult if going to the ED at the request of the ED dr for a stroke? Assume this is a non-Medicare…
Acute versus Chronic Conditions for Office E/M Services

Acute versus Chronic Conditions for Office E/M Services

March 24, 2022 Question: When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on…
Capsulectomy with Breast Reconstruction Implant Exchange

Capsulectomy with Breast Reconstruction Implant Exchange

March 24, 2022 Question: We billed 19371 (capsulectomy) with a breast reconstruction implant exchange (19342 – larger to smaller). We were denied 19371. Should we have used modifier 59 on…
Catheterization Codes in Vascular Coding

Catheterization Codes in Vascular Coding

March 24, 2022 Question:  Are there any vascular CPT codes that still allow separate reporting of selective and non-selective catheterization codes? Answer:  Yes, the following procedures still allow separate reporting…
Interposition Arthroplasty CMC Joint Denial

Interposition Arthroplasty CMC Joint Denial

March 24, 2022 Question: Our surgeon documented an interposition arthroplasty and removal of both the trapezoid and trapezium bones. I reported CPT code 25447 for the arthroplasty and 25210-59 for…
ER Visit Coding

ER Visit Coding

March 24, 2022 Question: What code do we charge for an ER visit when our physician was called to the ER by the ER doctor? The patient has Medicare. Answer:…
Counting Problems Addressed for Medical Decision Making

Counting Problems Addressed for Medical Decision Making

March 24, 2022 Question: If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?…
Hartmann or Partial Colectomy

Hartmann or Partial Colectomy

March 24, 2022 Question: My surgeon performed all the components of a Hartmann procedure 44143 but did not create a colostomy. Can we use 44143 with a -52 modifier? Answer:…
High Intensity Focused Ultrasound (MRgFUS)

High Intensity Focused Ultrasound (MRgFUS)

March 24, 2022 Question: We are going to start doing this new procedure called High Intensity Focused Ultrasound to treat essential tremor and other tremors. I can’t find a CPT…
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