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Problems Addressed for New E/M Guidelines

Problems Addressed for New E/M Guidelines

February 18, 2021 Question: Would bilateral large breasts, on a patient that we are recommending breast reduction, count as 2 problems in the new E/M guidelines for office visits? Answer:…
Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

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.…
Nonselective or Selective

Nonselective or Selective

February 18, 2021 Question: When does a nonselective catheterization become a selective catheterization? Answer: If the catheter (not just the wire) is manipulated into another vessel beyond the puncture site…
Injection of Blood to a Tendon

Injection of Blood to a Tendon

February 18, 2021 Question: Our orthopaedic sports medicine physician recently injected blood at a tendon insertion site for treatment of tendonitis. The staff drew the blood from the antecubital fossa…
New 2021 E/M Coding Guidelines

New 2021 E/M Coding Guidelines

February 18, 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…
Mohs Surgery Performed the Same Day as a Biopsy

Mohs Surgery Performed the Same Day as a Biopsy

February 18, 2021 Question: A patient was referred to our Mohs surgery for a lesion on the cheek. The family practice doctor did not do a biopsy but suspected skin…
Use of Modifier 52

Use of Modifier 52

February 18, 2021 Question: My surgeon was called into a laparoscopic operation that was already underway, to perform extensive lysis of adhesions. Does he need to use a modifier 52…
In-House MRI and “Counting” Data for New E/M Guidelines

In-House MRI and “Counting” Data for New E/M Guidelines

February 18, 2021 Question: We have an MRI in house which has made me confused about how to count the data for the neurosurgeon’s E/M code.  Please help. Answer: Good…
“Counting” Data for 2021 Office E/M Codes

“Counting” Data for 2021 Office E/M Codes

February 4, 2021 Question: I’m confused about the Data component for the new office visit guidelines. What do I get credit for when a patient brings in her mammogram report?…
Modifier 52 vs. 53

Modifier 52 vs. 53

February 4, 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…
Billing an Injection for Failed Attempts

Billing an Injection for Failed Attempts

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…
‘Incident To’ Services

‘Incident To’ Services

February 4, 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.…
Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

February 4, 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.…
Excision of Rheumatoid Nodules

Excision of Rheumatoid Nodules

February 4, 2021 Question: I excised a rheumatoid nodule on both the left and right elbow.  What CPT code do I report? Answer: You would report CPT code 24120 (excision…
Separate Procedure Billing

Separate Procedure Billing

February 4, 2021 Question: The surgeon performed an open colectomy and found a tear in the mesentery close to the incision, 44850 Suture of mesentery is listed as a “separate…
New 2021 E/M Coding Guidelines

New 2021 E/M Coding Guidelines

February 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…
Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

January 21, 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.…
Can I Bill for Fluoroscopy?

Can I Bill for Fluoroscopy?

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…
New 2021 E/M Coding Guidelines

New 2021 E/M Coding Guidelines

January 21, 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…
New 2021 E/M Coding Guidelines

New 2021 E/M Coding Guidelines

January 21, 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…
Significant Undermining of Free Flap Donor Site

Significant Undermining of Free Flap Donor Site

January 21, 2021 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…
Coding Intermediate Repairs

Coding Intermediate Repairs

January 21, 2021 Question: Can I report CPT 12052 for an intermediate repair of the cheek and nose.  The size of the defect of the cheek is 2.7 cm and…
New 2021 E/M Coding Guidelines

New 2021 E/M Coding Guidelines

January 21, 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…
Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

January 21, 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 Family History for New Patient Visits

Documenting Family History for New Patient Visits

December 17, 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 2021 Evaluation and Management Code Guidelines

New 2021 Evaluation and Management Code Guidelines

December 17, 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…
Need Help with a Diagnosis Code

Need Help with a Diagnosis Code

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…
New 2021 E/M Coding Guidelines

New 2021 E/M Coding Guidelines

December 17, 2020 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…
Carotid Artery Exploration with Free Flap to Oral Cavity

Carotid Artery Exploration with Free Flap to Oral Cavity

December 17, 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…
Wedge Excision with Reconstruction

Wedge Excision with Reconstruction

December 17, 2020 Question: My physician did a full thickness wedge excision with an Estlander flap of the right upper lip with reconstruction utilizing a cheek flap, adjacent tissue transfer.…
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