Author: The Coding Coach (Coding Coach)

Confusion About New 2021 E/M Guidelines
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Confusion About New 2021 E/M Guidelines

October 6, 2022 Question: The new guidelines that are coming out in 2021 for all types of E/M services, right? Answer: No. The new guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the current guidelines for all other E/M services, even consultations in the office. But good news, the...

Counting Laminectomy Levels
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Counting Laminectomy Levels

October 6, 2022 Question: I am confused and hoping you can clarify a coding question I have. I thought I understood how to report laminectomy levels, however, after recently reading an article in the AHA Coding Clinic HCPCS Volume 22, Number 2 Second Quarter 2022 publication, I doubt myself. The surgeon performs and documents a...

Biopsy Coding
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Biopsy Coding

October 6, 2022 Question: I work at an ENT clinic and my physician is doing biopsies of the inner cheek and soft palate and I’m not sure if this is coded as 11104 or goes under biopsy vestibule of mouth 40808? Thank you so much for your help with this! Answer: If the physician is...

Co Surgeon or Assistant?
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Co Surgeon or Assistant?

October 6, 2022 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 co-surgeon or assistant on the case? Answer: Neither. The vascular surgeon will report his work, repair of vessel, and you will report yours. *This response...

Coding for Trigeminal Neuralgia #1
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Coding for Trigeminal Neuralgia #1

October 6, 2022 Question: A retrosigmoid craniotomy was performed with microvascular decompression of the 5th nerve. The diagnosis was Trigeminal Neuralgia. How is this coded? Answer: This procedure is reported with code 61458, Craniotomy, suboccipital, for exploration or decompression of cranial nerves. *This response is based on the best information available as of 10/06/22.  ...

New vs Established Patient
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New vs Established Patient

September 22, 2022 Question: I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of...

Overreading a Diagnostic Imaging Study
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Overreading a Diagnostic Imaging Study

September 22, 2022 Question: I sent a patient out to the hospital for a CTA and the patient brought in the actual images and the radiologist’s report for me to review. Can I charge 76140 (Consultation on X-ray examination made elsewhere, written report) when I personally interpret those images and write my own report? Answer:...

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Coding Coaches