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Coding Joint Injections and a Trigger Point Injection Together

Coding Joint Injections and a Trigger Point Injection Together

January 23, 2020 Question: We had a denial for a knee injection and a trigger point injection in the neck. Our coding software said these 2 codes are bundled and…
Two Level ACDF (non-contiguous)

Two Level ACDF (non-contiguous)

January 23, 2020 Question: Our surgeon performed an ACDF at C2-3 and C6-7 through separate incisions for treatment of anterior fractures. We are wondering if we are able to report…
Keloid Scar Destruction

Keloid Scar Destruction

January 23, 2020 Question: What CPT code should you report for laser removal of a keloid scar? What should be documented in the procedure note? Answer: You would report 17110.…
Modifier XU with a Programming Code and Battery Change Code

Modifier XU with a Programming Code and Battery Change Code

January 23, 2020 Question: Our Medicare specialist has advised us to add modifier XU (modifier 59) to CPT code 95970 when billing DBS battery change (61885/61886). It looks to me…
Ear Exam Under Anesthesia

Ear Exam Under Anesthesia

January 23, 2020 Question: Our surgeon performed an evaluation of the external ear canal on a pediatric patient, under general anesthesia, because the child would not allow the surgeon to…
Catheterization Codes in Vascular Coding

Catheterization Codes in Vascular Coding

January 23, 2020 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…
Coding for Non-Biological Mesh Placement

Coding for Non-Biological Mesh Placement

January 23, 2020 Question: How do I report placement of a mesh implant in the abdomen that is not a biological implant and not for an open incisional hernia? Answer:…
Laceration and Fracture Repair

Laceration and Fracture Repair

January 23, 2020 Question: My physician is utilizing an open laceration on the patient’s chin for open reduction of a mandibular symphysis fracture and he wants to also charge for…
Unspecified or Uncertain Behavior

Unspecified or Uncertain Behavior

January 9, 2020 Question: My provider insists on calling some lesions uncertain behavior because he is suspicious of cancer. This is before the pathologist has given a report. Should these…
Modifier -52 or -53

Modifier -52 or -53

January 9, 2020 Question: Physician was performing a spine injection and the patient chose to only have local anesthesia. During the procedure (before the medication was injected) the patient was…
Use of Cross Links with Posterior Instrumentation

Use of Cross Links with Posterior Instrumentation

January 9, 2020 Question: We have a new physician who has joined our practice and is documenting use of cross links as well as the pedicle screws and rods is…
Postop Tympanotomy Tube Visit

Postop Tympanotomy Tube Visit

January 9, 2020 Question: I have a question about post op visits for PE tubes (code 69436). As you know, these have a 10 day global period but my group…
Dislocation CPT Codes: Traumatic vs Non-traumatic

Dislocation CPT Codes: Traumatic vs Non-traumatic

January 9, 2020 Question: Is it appropriate to report CPT code 28645 for both traumatic and non-traumatic dislocations? Answer: Yes, CPT code 28645 (Open treatment of metatarsophalangeal joint dislocation, includes…
Documenting Codes In the Procedure Report

Documenting Codes In the Procedure Report

January 9, 2020 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…
Renal Angiogram Coding

Renal Angiogram Coding

January 9, 2020 Question: Is catheterization separately reported with renal angiograms? Answer: No. The renal angiogram codes, see table below, include all catherization.  The codes are selected by order of…
Unspecified vs. Uncertain Behavior Skin Lesion Diagnosis Code

Unspecified vs. Uncertain Behavior Skin Lesion Diagnosis Code

January 9, 2020 Question: Can you refresh my memory on when to use the diagnosis code for skin lesion “uncertain behavior” vs “uncertain behavior”?  I know one is to be…
Use of a Scribe

Use of a Scribe

December 19, 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…
Trigger Point Injections Coding: Muscle or Muscle Group

Trigger Point Injections Coding: Muscle or Muscle Group

December 19, 2019 Question: One of our Providers recently completed Trigger Point injections to Bilateral Thoracic Paraspinals and Bilateral Trapezius in the same setting for a patient. When we bill for…
Measurements for Excision of Lesion Removal

Measurements for Excision of Lesion Removal

December 19, 2019 Question: Our coder sometimes uses measurements listed in the pathology report for lesion excisions, because the measurements are unclear or missing in the procedure note. Is this…
Diagnosis Code for “End of Life” DBS Battery

Diagnosis Code for “End of Life” DBS Battery

December 19, 2019 Question: What would be the appropriate diagnosis code (ICD-10-CM) for “end of life battery” when we have to change the generator in a deep brain stimulator patient.…
Implantation of Biologic Implants

Implantation of Biologic Implants

December 19, 2019 Question: Can we use 15777 Implantation of biologic implant (e.g. acellular dermal matrix) for soft tissue reinforcement for other tissues beside the breast or trunk? Answer: Code…
Osteoporosis Clinic

Osteoporosis Clinic

December 19, 2019 Question: We have an osteoporosis clinic where our providers see patients on referral. Many times this referral comes from our own colleagues after the patient is seen…
Coding for ICG Imaging

Coding for ICG Imaging

December 19, 2019 Question: Can you give guidance on CPT 15860 as it pertains to colorectal surgery? My surgeons have been using this code when they use the isocyanine green…
Pelvic Angiograms

Pelvic Angiograms

December 19, 2019 Question: Is angiogram of the iliac arteries reported with the pelvic angiogram code, 75736? Answer: No, code 75736, Angiography, pelvis, selective or superselective is only reported with…
Billing for Multiple Embolectomies

Billing for Multiple Embolectomies

December 5, 2019 Question: How do we code multiple embolectomies of the aorta when using 34201? Do we code units by the number removed? Answer: 34201, Embolectomy or thrombectomy, with…
Periacetabular Osteotomy

Periacetabular Osteotomy

December 5, 2019 Question: We have a new pediatric orthopaedic surgeon who has joined our practice. He recently performed periacetabular osteotomies for hip dysplasia. He wants us to report CPT…
VP Shunt Reprogramming

VP Shunt Reprogramming

December 5, 2019 Question: We had a patient show up in our office, after an MRI ordered by another physician, and wanted their shunt settings checked. We checked the shunt…
Coding Bilateral Percutaneously Placed Spinal Cord Stimulator Electrodes

Coding Bilateral Percutaneously Placed Spinal Cord Stimulator Electrodes

December 5, 2019 Question: If bilateral spinal electrode are placed percutaneously, 63650, can both be reported? Answer: Yes, if two electrodes are placed, bilaterally, both may be reported.  See the…
Billing for Incisional Biopsies

Billing for Incisional Biopsies

December 5, 2019 Question: How do we code for 2 separate incisional biopsies – one on the back and another on the patient’s lower lip? Do we use 11106 and…
Tattoo Redo After Reconstruction

Tattoo Redo After Reconstruction

December 5, 2019 Question: A patient came to us for a redo of nipple micropigmentation, as she was not pleased with the result from the tattoo artist. Our surgeon did…
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