November 30, 2023 Question: My physician is billing office visits 99202-99215 based on time only. Is this best practice? Answer: The E/M services 99202-99205 are based on either medical decision making or time.. Practitioners may choose to either bill by time or medical decision making. The practitioner should evaluate each patient encounter to determine which...
November 30, 2023 Question: When we take the patient to the OR to debride a wound or burn using Versajet what is the best CPT code to report? If we use a knife or curette or scissor to debride is that coded differently that a versajet? Answer: The depth of the wound determines the CPT...
November 30, 2023 Question: When a provider preforms less than 10 stab phlebectomies what is the comparison code? Answer: I would recommend using CPT 37999 for the stab phlebectomies. Make sure you are looking at the providers documentation as it depends on the number of incisions the providers make. *This response is based on the...
November 30, 2023 Question: We have a major hip and knee practice. We frequently see patients back for repeat injections; typically, we do not report the E&M, and report the injection only. Recently, in one of our coding meetings, we discussed “well, what if the patient presents with a new injury and the physician re-injects...
November 30, 2023 Question: We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was...
November 30, 2023 Question: Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of...
November 30, 2023 Question: As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy? Answer: No, that resection is considered part of the appendectomy procedure and not separately reported. *This response is based on the best information available as of...
November 16, 2023 Question: I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the...
November 16, 2023 Question: Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of...
