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Lymph Node Biopsy

Lymph Node Biopsy

July 9, 2020 Question: I took out 3 deep cervical nodes for biopsy on the left side. Can I bill 38510 x 3? Answer: No – you’d report 38510 once…
Are Wound Vacs Separately Reportable?

Are Wound Vacs Separately Reportable?

July 9, 2020 Question: I’m a pediatric orthopedic surgeon.  Some of my team are reporting the NPWT codes 97605 and 97606 when applying wound vacs after closing at the completion…
Removal of sEEG Electrodes

Removal of sEEG Electrodes

July 9, 2020 Question: I placed subdural stereo-EEG electrodes for epilepsy monitoring. What is the code for removal of these electrodes? I’ve been billing 61880 for removal of each electrode…
Documenting Family History in New Visits

Documenting Family History in New Visits

July 9, 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.…
Soft Tissue Tumor Removal

Soft Tissue Tumor Removal

July 9 , 2020 Question: My physician removed a soft tissue tumor on the patient’s foot measuring 1.2 cm. Documentation indicates subcutaneous. He is coding this as a benign excision…
Botox and Image Guidance

Botox and Image Guidance

July 9, 2020 Question: Code 64615 says bilateral for the injection of Botox for chronic migraine. Does that mean we can also bill 95873 twice? Answer: Although not explicitly stated…
Complex Closure of Free Flap Donor Site

Complex Closure of Free Flap Donor Site

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…
Billing for Vascular Access

Billing for Vascular Access

July 9, 2020 Question: I’m new to vascular coding, can we bill for vascular access for a catheterization? The provider documents this, so I’m thinking I am missing a code.…
“Counting” Levels for Posterior Spinal Instrumentation

“Counting” Levels for Posterior Spinal Instrumentation

June 25, 2020 Question: When placing pedicle screws, do I bill per pedicle screw or per level? For example, pedicle screws and rods at L5-S1, is it 22840 x 4…
Billing E/M Visits During the Global Period

Billing E/M Visits During the Global Period

June 25, 2020 Question: Can I bill for different diagnosis codes for conditions/problems when seeing a patient in the hospital after surgery, but during the stay of a major surgery?…
Biopsy Diagnosis

Biopsy Diagnosis

June 25, 2020 Question: What is the appropriate diagnosis code to submit when I do a skin biopsy of the eyelid? Answer: If you are submitting the claim the same…
Blood Patch with Epidural

Blood Patch with Epidural

June 25, 2020 Question: My anesthesiologist had to perform a blood patch on a patient who received an epidural the day before. Can we bill for this? Answer: It depends.…
Co-Surgery Due to Complex Procedure

Co-Surgery Due to Complex Procedure

June 25, 2020 Question: I have 2 vascular surgeons from the same practice that want to bill co-surgery for a complex open abdominal aneurysm repair. They both performed the same…
Excision External Ear

Excision External Ear

June 25, 2020 Question: I did a partial excision of the left ear wedge with a layered closure. Can I code 69110 and a complex repair code since 69110 says…
Cosmetic Procedures in a Functional World

Cosmetic Procedures in a Functional World

June 25, 2020 Question: We are starting to do cosmetic facial plastic procedures in our ENT practice. How do I code/bill a cosmetic procedure such as a rhinoplasty versus when…
2021 MDM Credit for Taking a History!

2021 MDM Credit for Taking a History!

June 25, 2020 Question: I am a pediatric orthopaedic surgeon and many of my patients are too young to give a history. My coders have never given me medical decision…
Bilateral Posterolateral Fusion

Bilateral Posterolateral Fusion

June 11, 2020 Question: I did a posterior lumbar fusion bilaterally. Can I bill 22612 with modifier 50 for bilateral procedures? I looked at CPT and it doesn’t say that…
Malignant Lesions on Lip

Malignant Lesions on Lip

June 11, 2020 Question: What diagnosis code should I use for a patient treated for two malignant lesions, one in the mucosa of the upper lip and a second in…
Intraoperative Laryngeal Nerve Monitoring with Thyroidectomy Procedures

Intraoperative Laryngeal Nerve Monitoring with Thyroidectomy Procedures

June 11, 2020 Question: Are we able to bill for laryngeal nerve monitoring with thyroidectomy procedure? Answer: No – CPT is very clear in that intraoperative monitoring (e.g., 95940, 95941)…
Coding a Diverting Ileostomy with a Low Anterior Resection/Low Pelvic Anastomosis Partial Colectomy

Coding a Diverting Ileostomy with a Low Anterior Resection/Low Pelvic Anastomosis Partial Colectomy

June 11, 2020 Question: Instead of a colostomy as described in the laparoscopic CPT codes 44208 or the open code, 44146, my doctor does a diverting ileostomy. We have been…
Established Patient New Problem

Established Patient New Problem

June 11, 2020 Question: I saw an established patient for her last lumbar epidural in the series and she now complains of right upper extremity radiculopathy. I spent over 30…
Seroma after Breast Reconstruction

Seroma after Breast Reconstruction

June 11, 2020 Question: During the post-operative global period following breast reconstruction the patient presents with a seroma. Can I bill for the seroma excision and also bill for an…
Tarsal Tunnel Injection

Tarsal Tunnel Injection

June 11, 2020 Question: I am writing on behalf of myself and my other Orthopedic coding colleagues regarding tarsal tunnel injections. We have done some research on this and cannot…
Payment and Coding Changes you need to know with Open Exposure in EVAR

Payment and Coding Changes you need to know with Open Exposure in EVAR

June 11, 2020 Question: Does it matter that the open exposure codes are now add-on codes? Does that change payment or coding in any way? Answer: Yes, this change has…
Repair of a Semi-Circular Canal Dehiscence with ENT

Repair of a Semi-Circular Canal Dehiscence with ENT

May 28, 2020 Question: We are doing a combined case with ENT and are not sure how to code it. The patient has a semi-circular canal dehiscence of the temporal…
Intraoperative ICG Dye Angiography

Intraoperative ICG Dye Angiography

May 28, 2020 Question: Can we bill the 92242 for the indocyanine green injection intraoperatively, for example to assess perfusion after a colectomy or other abdominal procedure?  Can we bill…
AK’s with Biopsy on the Same Date

AK’s with Biopsy on the Same Date

May 28, 2020 Question: We had a Medicare patient who came in with AKs and a lesion on the eyelid. Twenty AKs were destroyed on the patient’s chest and scalp…
Genicular Nerve RFA

Genicular Nerve RFA

May 29, 2020 Question: I’m new to coding. What code would I use for radiofrequency ablation of the genicular nerve? Answer: You’re in luck! There is a new code in…
Billing code 34713, using a 12 French or larger catheter with EVAR

Billing code 34713, using a 12 French or larger catheter with EVAR

May 28, 2020 Question: I almost always use a 12 French or larger catheter for placing the main body for EVAR. Do I always bill the new code 34713, when…
DIEP Co-Surgery

DIEP Co-Surgery

May 28, 2020 Question: Hello! I have a plastic surgery question. I perform DIEP surgeries and when I do a bilateral DIEP I have a colleague scrub with me, and…
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