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MDM Credit for 2021

MDM Credit for 2021

April 29, 2021 Question:  I am a pain management specialist. I have a patient who was referred to my office who has dementia and was unable to provide her medical…
Laceration and Fracture Repair

Laceration and Fracture Repair

April 29, 2021 Question: My physician is utilizing an open laceration on the patients chin for open reduction of a mandibular symphysis fracture. He wants to also charge for complex…
Fem-Fem Bypass

Fem-Fem Bypass

April 29, 2021 Question: How is a left femoral to right femoral artery bypass with PTFE reported? Answer: Report code 35661, Bypass graft, with other than vein, femoral- femoral. This…
Separate Procedure Billing

Separate Procedure Billing

April 29, 2021 Question: I am new to coding and have a question. I remember studying about “separate procedures” and have my first operative note that includes a code that…
Cerumen Removal

Cerumen Removal

April 29, 2021 Question: If someone comes in for ear cleaning do you bill 69210 only or can you also bill an E/M code with modifier 25 and 69210? Answer:…
New Evaluation and Management Guidelines for 2021 for Office Visits

New Evaluation and Management Guidelines for 2021 for Office Visits

April 29, 2021 Question: I work in a Dermatology practice and we see just a few Medicare patients. The physician believes the revised 2021 E/M guidelines will not impact our…
OOOPs. I Nicked a Vessel. Can I Bill for Repairing it?

OOOPs. I Nicked a Vessel. Can I Bill for Repairing it?

April 29, 2021 Question: The surgeon accidentally nicked a vessel not involved in the bypass being performed, can he bill for repair of vessel since he had to repair it?…
Postop Pain Management, Intraop Fluoroscopy, Intraop Ultrasound

Postop Pain Management, Intraop Fluoroscopy, Intraop Ultrasound

April 29, 2021 Question: I just finished my residency and am in an employed situation.  In reviewing my end-of-month RVU reports, I’m seeing a lot of the codes I submitted…
Modifier 52 vs. 53

Modifier 52 vs. 53

April 15, 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…
Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 15, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the…
Embolization and Catheterization

Embolization and Catheterization

April 15, 2021 Question: I was told catheterization is included in the embolization codes, 37241-37244. Is that correct? Answer: No, per CPT catheterization is separately reported with all the embolization…
2021 E/M Coding Guidelines: Time for Teaching Physician Services

2021 E/M Coding Guidelines: Time for Teaching Physician Services

April 15, 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 Time and Medical Decision Making in the 2021 E/M Code Revisions

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 15, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the…
Skin Tags

Skin Tags

April 15, 2021 Question: If a physician removes skin tags by shaving can we report 11300? Answer: If you are removing skin tags you would report 11200 (Removal of skin…
Co-Surgeon or Assistant?

Co-Surgeon or Assistant?

April 15, 2021 Question: A vascular surgeon is requested to come to the OR to repair a blood vessel that my surgeon inadvertently nicked during a colectomy. Is he a…
New E/M Guidelines: Confusion

New E/M Guidelines: Confusion

April 15, 2021 Question: I’m still confused about the new E/M guidelines.  Do these new guidelines apply to the consultation codes? Also, I have so many more questions, can you…
Incident to Services

Incident to Services

April 1, 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.…
Number of Units for ADM Code (+15777)

Number of Units for ADM Code (+15777)

April 1, 2021 Question: I use two ADMs on each breast during a tissue expander reconstruction. Can I bill +15777 x 4 units? Answer: No, you’ll use the code +15777…
Lesion Crossing Two Territories

Lesion Crossing Two Territories

April 1, 2021 Question: Our vascular surgeon did a single intervention on a lesion that was at the juncture of the femoral/popliteal and tibial/peritoneal territories. Can we charge for two…
Reading an MRI Performed at Outside Institution

Reading an MRI Performed at Outside Institution

April 1, 2021 Question: A new patient presents with a CD of an MRI that was performed at an outside institution and was read by the radiologist. There was no…
Problems Addressed for New E/M Guidelines

Problems Addressed for New E/M Guidelines

April 1, 2021 Question: Would bilateral recurrent acute otitis media, on a patient that will need tympanostomy tubes, count as 2 problems in the new E/M guidelines for office visits?…
Coding an Epidermal Inclusion Cyst

Coding an Epidermal Inclusion Cyst

April 1, 2021 Question: I excised an EIC lesion on the chest.  I coded this as D48.5 but my coder says this is the wrong diagnosis code.  What is the…
Port Placement within a Global Period   

Port Placement within a Global Period   

April 1, 2021 Question: Our general surgeon performed a radical mastectomy and is now performing a port placement, at a separate session, for the patient. What modifier should we use…
Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 1, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the…
E/M Guidelines for 2021

E/M Guidelines for 2021

March 18, 2021 Question: My physicians have decided they would prefer to continue to use the E/M 1995/1997 guidelines for office visits instead of the new 2021 guidelines. Do we…
Oncoplastic Reconstruction

Oncoplastic Reconstruction

March 18, 2021 Question:  I just realized CPT 19366 was deleted in 2021. Now what code do I use for an oncoplastic reconstruction? Answer: You’re right – CPT 19366 (Breast…
Venogram and Catheterization

Venogram and Catheterization

March 18, 2021 Question: During a catheterization the surgeon performed a venogram. I don’t see that these procedures are bundled, is that correct? Answer: Venous catheterization codes are separately reported…
Medication Documentation

Medication Documentation

March 18, 2021 Question: We are switching to a new EHR system. We have not always had great compliance with our providers documenting what we feel needs to be documented…
In-House CT and “Counting” Data for New E/M Guidelines

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

March 18, 2021 Question: We have an in-house CT which has made me confused about how to count the data for the my ENT’s E/M code.  Please help. Answer: Good…
Diagnosis Code Help for a Malignant Lesion

Diagnosis Code Help for a Malignant Lesion

March 18, 2021 Question: A 74-year-old male Medicare patient came into our office and was treated for two malignant lesions, one in the mucosa of the upper lip and a…
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