Author: The Coding Coach (Coding Coach)

E/M Visit During the Global Period
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E/M Visit During the Global Period

November 17, 2022 Question: Can I bill an office visit in the global period if the diagnosis is different from why I did the original procedure? Answer: Yes, as long as the diagnosis is not for a related issue (e.g., complication from the original procedure). The documentation must be clear that the condition is unrelated...

Cleft Lip Repair
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Cleft Lip Repair

November 17, 2022 Question: What CPT code do I use to report the repair of the cleft lip with a cross lip pedicle flap and sectioning and inserting the pedicle? I was told to report CPT 40527 Answer: The correct code to report is 40761. CPT 40527 does not include sectioning and inserting the pedicle....

Stent vs. Embolization or Both
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Stent vs. Embolization or Both

November 17, 2022 Question: If the surgeon uses a covered stent and performs an embolization on a patient with a pseudoaneurysm, can we bill for both the stent and removal of the embolus? Answer: If a covered stent is deployed as the sole management of an aneurysm, pseudoaneurysm or vascular extravasation, then the stent deployment...

E&M Coding Based on Time
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E&M Coding Based on Time

November 17, 2022 Question: Our physicians default to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own independent interpretation of X-Rays (we bill globally), perform injections, and reduce fractures in the office. They are counting the...

Billing an E/M Service on the Same Day as an Oral Food Challenge
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Billing an E/M Service on the Same Day as an Oral Food Challenge

November 17, 2022 Question: My physician always bills an E/M service with CPT codes 95076/95079.  Is this allowed? Answer: It’s rare to bill an E/M code with an oral challenge unless the provider needs to treat for a reaction (intervention therapy – a separate service) or the provider saw the patient for an unrelated office...

Denial for 99214
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Denial for 99214

November 17, 2022 Question: I work with Dermatologists. I have taken a couple of your online webinars. I have a question regarding a denial of office visit 99214, I hope you can answer. The denial indicates that medical records do not support the level of service. In that type of situation, can we rebill the...

What Does “Separate Procedure “Mean in a CPT Code Description?
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What Does “Separate Procedure “Mean in a CPT Code Description?

November 17, 2022 Question: What does “separate procedure” mean when it follows a CPT code description? Answer: Per CPT: Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate...

Counting Laminectomy Levels
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Counting Laminectomy Levels

November 17, 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...

Soft Tissue Tumor Excisions
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Soft Tissue Tumor Excisions

November 3, 2022 Question: My physician performed two soft tissue tumor excisions in different areas on the scalp. They measured 1.0 cm and 1.5 cm. Can I bill for both? Also can I report a layered closure. Answer: You would report CPT 21011 (excision soft tissue tumor, scalp 2cm or less) for the first excision...

Dialysis Circuit Revision
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Dialysis Circuit Revision

November 3, 2022 Question: My vascular surgeon performed a dialysis circuit open revision, and had to remove subcutaneous fat during the procedure. He said this was a more complex procedure than usual, so is there another code to use besides 36832? Answer: Removing excess subcutaneous fat is included in the work for 36832, so this...

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Coding Coaches