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Documenting Codes In the Procedure Report

Documenting Codes In the Procedure Report

October 14, 2021 Question: I’ve been dictating CPT and ICD-10-CM codes in my procedure note so that my coder knows what to bill. Recently, we had an insurance company call…
Counting Problems Addressed for Medical Decision Making

Counting Problems Addressed for Medical Decision Making

October 14, 2021 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?…
How Do You Define “No Qualified Resident Available”?

How Do You Define “No Qualified Resident Available”?

October 14, 2021 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…
Balloon Spacer in the Shoulder

Balloon Spacer in the Shoulder

October 14, 2021 Question: Our orthopaedic shoulder surgeon treated a patient with two massive rotator cuff tears that were not amenable to repair. Due to patient age, the patient would…
Code for Smell Testing

Code for Smell Testing

October 14, 2021 Question: Is there a code for smell testing that incorporates olfactory threshold and identification? Answer: Unfortunately, no. You’ll need to use an unlisted code such as 92700.…
MOHS Surgery

MOHS Surgery

October 14, 2021 Question: My Mohs surgeon was performing Mohs surgery on the scalp and completed stage 1 and 2 but cancer was still evident in the margins.  The patient…
Wound Vac Billing

Wound Vac Billing

October 14, 2021 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…
Postop Pain Control

Postop Pain Control

October 14, 2021 Question: I’m placing catheters in the erector spinae plane through a separate puncture after the surgical wound is closed.  We are billing 64463 [Paravertebral block (PVB) (paraspinous…
Denial for Transforaminal Epidural

Denial for Transforaminal Epidural

September 30, 2021 Question: I was told to use 0230T for a tranforaminal epidural injection (S1)with ultrasound. I sent to claim to Medicare in March 2021 and the claims was…
Diagnosis Issue for Breast Reconstruction Wound Debridement

Diagnosis Issue for Breast Reconstruction Wound Debridement

September 30, 2021 Question: We did a debridement and repair of a wound dehiscence on a breast reconstruction patient. The denial said we did not have the right diagnosis code.…
Coding for In-Stent Carotid Stenosis

Coding for In-Stent Carotid Stenosis

September 30, 2021 Question: How is angioplasty of a previously placed carotid stent that is now occluded billed? Answer: For a patient treated with angioplasty for with occlusion in a…
Reconstruction of the ATFL and CFL

Reconstruction of the ATFL and CFL

September 30, 2021 Question: Our foot and ankle surgeon performed a reconstruction of the ATFL and the CFL ligament in the left leg for a chronic injury. We are looking…
Medical Decision Making Credit for Ordering an Audiogram

Medical Decision Making Credit for Ordering an Audiogram

September 30, 2021 Question: My ENT doctor ordered an audiogram to be done by our audiologist. The doctor billed for the audiogram to a non-Medicare payor because the audiologist is…
Steroid Injections into the Palm

Steroid Injections into the Palm

September 30, 2021 Question: I did several steroid injections on the patient’s palm for psoriasis.  I am not sure what CPT code to use. Can you provide me with the…
Total Thyroidectomy with Re-Implant of a Parathyroid Gland

Total Thyroidectomy with Re-Implant of a Parathyroid Gland

September 30, 2021 Question: In the past, when I did a total thyroidectomy and I needed to re-implant a parathyroid gland I would also code 60512. I am now being…
Ventricular Drain Postop Tumor Resection

Ventricular Drain Postop Tumor Resection

September 30, 2021 Question: Do I use a modifier 58 (staged procedure) on the ventricular drain code when it’s done in the ICU after a craniotomy for tumor? Answer: That…
Chemodenervation

Chemodenervation

September 16, 2021 Question: A patient with multiple sclerosis came into our pain clinic with spasms to the left and right upper arms. The physician injected the following muscles using…
Complex Closure of Full Thickness Graft Site

Complex Closure of Full Thickness Graft Site

September 16, 2021 Question: We billed 15260 (full thickness graft, ear) and 13132 (complex repair, ear) and were not paid for the complex repair. Can you help us with an…
Billing Diagnostic Angiograms with an Intervention

Billing Diagnostic Angiograms with an Intervention

September 16, 2021 Question: When are diagnostic angiograms and an intervention (angioplasty, stent, etc.) both billable? Answer: Diagnostic angiograms are separately billable during an intervention if no adequate or prior…
Dry Needling

Dry Needling

September 16, 2021 Question: Our pain management physician stated he performed a trigger point injection into 1 muscle. In reviewing the procedure note we find that the documentation supports dry…
Topical Anesthesia for Nasal Endoscopy

Topical Anesthesia for Nasal Endoscopy

September 16, 2021 Question: One of our doctors saw a patient and billed 31231 (nasal endoscopy). The doctor did not document that a topical vasoconstrictive agent was applied.  Does the…
XTRAC Therapy

XTRAC Therapy

September 16, 2021 Question: We have recently begun treating our psoriasis patients  using XTRAC laser therapy.  I have looked extensively and cannot find a CPT code for this procedure.  Can…
Laparoscopic or Open, How Can You Tell?

Laparoscopic or Open, How Can You Tell?

September 16, 2021 Question: If a code does not specify whether the procedure described is laparoscopic or open, is it acceptable to use it if the procedure was performed laparoscopically?…
Counting Problems Addressed for Medical Decision Making

Counting Problems Addressed for Medical Decision Making

September 16, 2021 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?…
Nerve Block

Nerve Block

September 2, 2021 Question: My doctor did a regional thoracic nerve block. He performed three injections at three intercostals levels. How do I code that? Answer: You would report 64420…
Employee Certification for EHR Entry

Employee Certification for EHR Entry

September 2, 2021 Question: I heard that a medical assistant who enters the patient’s medications into the electronic health record must be certified. Is this true? Answer: Actually, Medicare requires…
Coding TCAR

Coding TCAR

September 2, 2021 Question: What is TCAR and how is it coded? Answer: TCAR stands for Transcarotid Artery Revascularization. It is essentially an open carotid stent procedure. A small incision…
Documenting Codes In the Procedure Report

Documenting Codes In the Procedure Report

September 2, 2021 Question: I’ve been dictating CPT and ICD-10-CM codes in my procedure note so that my coder knows what to bill. Recently, we had an insurance company call…
Harvest of Graft for Repair of Nasal Vestibular Stenosis

Harvest of Graft for Repair of Nasal Vestibular Stenosis

September 2, 2021 Question: We did a septoplasty and repair of nasal vestibular stenosis with spreader grafts using septal cartilage. We billed these codes: 30465, 30520 and 20912.  Medicare does…
Treatment for Psoriasis

Treatment for Psoriasis

September 2, 2021 Question: I am new to Dermatology coding and need some help.  My physician saw a patient with psoriasis and the documentation says she performed light therapy on…
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