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Shunt Revision

Shunt Revision

November 14, 2019 Question: I had to replace the ventricular catheter and the valve on a patient with a VP shunt.  What code should I use? Answer: Actually you get…
Binocular Microscopy

Binocular Microscopy

November 14, 2019 Question: I oftentimes bill and E/M code with modifier 25 for an office visit and 92504-50 (1 unit) for the binocular microscopy to Medicare.  I get denied…
Modifiers for Free Flap Breast Reconstruction

Modifiers for Free Flap Breast Reconstruction

November 14, 2019 Question: Do the free flap breast reconstruction codes, 19364 and S2068, allow billing for surgeon, co-surgeon and assistant? Answer: CPT 19364 does allow payment for the surgeon,…
Definition of Simple versus Complicated

Definition of Simple versus Complicated

November 14, 2019 Question: What is the definition of simple vs complicated for the I&D codes 10060 versus 10061? Answer: While CPT doesn’t define the difference between “simple” and “complicated”,…
SI Joint Injection

SI Joint Injection

November 14, 2019 Question: My MD performed an SI joint injection with ultrasound guidance in the office. What is the appropriate coding for this procedure? I have seen information regarding…
Is a 99214 supported?

Is a 99214 supported?

November 14, 2019 Question: We have patients who return to the clinic for results of MRI or other diagnostic tests.  The physician performs a repeat exam, reviews the images, and…
Coding Right and Left Carotid Stents at Different Operative Sessions

Coding Right and Left Carotid Stents at Different Operative Sessions

November 14, 2019 Question: The physician staged a patient’s bilateral carotid stent with embolic protection procedures.  The right carotid stent was done first and then the 6 weeks later the…
Use of a Scribe

Use of a Scribe

November 14, 2019 Question: We are hiring a scribe for the doctor because it will help improve his documentation.  Is there anything we need to know about how to document…
New Patient, or Not?

New Patient, or Not?

October 31, 2019 Question: If I see a new patient in consultation for a suspicious skin lesion and release them to their primary care provider and they come back to…
How do you define “No Qualified Resident Available”?

How do you define “No Qualified Resident Available”?

October 31, 2019 Question: Our physicians utilize residents during surgery but we have a discrepancy in what is considered a “Qualified Resident”. Some physicians consider a resident qualified to assist…
Thyroidectomy and Parathyroidectomy

Thyroidectomy and Parathyroidectomy

October 31, 2019 Question: Can we charge a thyroidectomy (e.g., 60240) when we do a parathyroidectomy (60500) Answer: Yes, but only if there is different pathology to support 60500.  The…
Modifier 58 or 78

Modifier 58 or 78

October 31, 2019 Question: We have a patient scheduled for manipulation under anesthesia for arthrofibrosis during the post-operative period for a total knee arthroplasty. The patient was informed prior to…
Providing the exposure for a neurosurgeon. How is it coded?

Providing the exposure for a neurosurgeon. How is it coded?

  October 31, 2019 Question: Our vascular surgeon provided exposure for a neurosurgeon for a 3 level anterior spine procedure. We were told to bill 22558 only. Is that correct?…
Consultation Request

Consultation Request

  October 31, 2019 Question: Would you mind giving your opinion? I saw a patient from urgent care yesterday with no formal referral order put in. But the patient says…
Augmentation of Pedicle Screws

Augmentation of Pedicle Screws

October 31, 2019 Question: I injected cement into the pedicles to augment screws in a patient with osteoporosis. My coder suggested using +22859 (Insertion of intervertebral biomechanical device(s) (eg, synthetic…
Postoperative Incision Drainage

Postoperative Incision Drainage

  October 31, 2019 Question: A patient had bilateral breast augmentation 5 weeks ago. She developed some drainage out of the lateral aspect of her left breast inframammary incision. The…
T9-11 Epidural Tumor Removal

T9-11 Epidural Tumor Removal

October 17, 2019 Question: I did bilateral laminectomies at T9, T10, T11 and removed an epidural tumor. I billed 63276-50, 63276-50-59 and 63276-50-59 but got paid for only 63276-50. Should…
Removal of Breast Implant with Capsulectomy

Removal of Breast Implant with Capsulectomy

October 17, 2019 Question: My doctor specializes in breast reconstruction and has been asking me to bill 19328 (removal of intact breast implant) along with 19371 (capsulectomy) when he has…
Providing the exposure for a neurosurgeon. How is it coded?

Providing the exposure for a neurosurgeon. How is it coded?

October 17, 2019 Question: A neurosurgeon asked my vascular surgeon to perform the exposure for an anterior spine procedure.  Does he report an exploratory lap his work? Answer: No. providing…
E/M and Fracture Manipulation

E/M and Fracture Manipulation

October 17, 2019 Question: We have joined a new health system and the coding staff members (new to orthopaedics) are removing all E/M-57 services when reported with a fracture manipulation…
PTH Blood Draw with a Parathyroidectomy

PTH Blood Draw with a Parathyroidectomy

October 17, 2019 Question: Can you code a PTH (blood draw, during a parathyroidectomy? Answer: Monitoring the Parathyroid hormone (PTH), including the blood draw, is included in the parathyroidectomy and…
APP Billing

APP Billing

October 17, 2019 Question: Our physicians have instructed us to bill under a physician’s NPI number for all Advanced Practitioners (PAs and NPs) for all patients for Medicare as we…
Post-Op Tonsillectomy Bleed

Post-Op Tonsillectomy Bleed

October 17, 2019 Question: A patient had a T&A and had a bleed. She came to office and saw my doctor.  My doctor wants to charge an office visit with a…
What Constitutes the Trunk for Complex Repairs?

What Constitutes the Trunk for Complex Repairs?

October 17, 2019 Question: CPT question for anatomy: When coding complex repairs CPT 13100-13102 for complex repair of trunk. What body area is included in the “Trunk”.  For simple and…
Diagnosis Code for Post Op Visits

Diagnosis Code for Post Op Visits

July 11, 2019 Question: What’s the best way to do the diagnosis coding for postop visits? I mean, does it really matter since we aren’t billing for a visit? Answer:…
Coding for FAST Exams

Coding for FAST Exams

October 3, 2019 Question: I was told I cannot bill for FAST exams done in the ED for a trauma patient, if permanent recordings of the images are not retained.…
Nerve Block for Postoperative Pain Management

Nerve Block for Postoperative Pain Management

October 3, 2019 Question: My doctor has introduced us to a code he would like to bill.  I have researched this pretty heavily and included another coder in the research…
Hematoma I&D with Fasciotomy

Hematoma I&D with Fasciotomy

October 3, 2019 Question: Our surgeon performed an I&D of a hematoma in the same compartment as an anterior and lateral fasciotomy in the leg for compartment syndrome. I submitted…
Excision versus Biopsy

Excision versus Biopsy

October 3, 2019 Question: Does this code description require a scalpel? If you do a punch excision – margins are clear. Can that be billed as excision ? Does excision…
Prescription Refill Visits

Prescription Refill Visits

October 3, 2019 Question: We get calls from patients to renew their medications. When the patient comes to office to pick up prescription, can we bill for a nurse visit…
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