Category: CC-Orthopaedics

Using a Scribe
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Using a Scribe

August 3, 2023 Question: I would like to know if it is compliant for the doctor to make corrections or additional comments on the note written by the scribe? For example, the note is written by the scribe, but at the end of the day the doctor reviews the note and makes correction if he...

Radiology Reports
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Radiology Reports

July 6, 2023 Question: Earlier this year, I attended an education session (not provided by KZA) where radiology reports were discussed. We have been going to KZA courses for many years and have the workbook pages with the history of the requirement and definition change for reports. We were confident we knew the documentation requirements...

Syndesmosis Repair
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Syndesmosis Repair

June 22, 2023 Question: I coded a case for one of our surgeons where he did an ORIF of a distal tibia/fibula fracture (Pilon) and syndesmosis repair and documented a separate diagnosis to support each procedure. I recommended CPT code 27828 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon...

POS for Hospital Services
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POS for Hospital Services

June 8, 2023 Question: We are wondering if you can help address a discussion in our office related to the coding rule changes for hospital services. CPT instructs to report 99221-99223 (inpatient hospital/observation) and 99231-99223 (subsequent hospital/observation) for both inpatient and observation services. Our hospital does not have a dedicated outpatient observation area; all patients...

Retrocalcaneal Bursectomy
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Retrocalcaneal Bursectomy

May 11, 2023 Question: Our surgeon performed a repair of an Achilles tendon, excision Haglund’s deformity of the calcaneus and retrocalcaneal bursectomy. Are we able to code the bursectomy in addition to the repair and excision of Haglund’s? Thank you in advance for your assistance. Answer: Thank you for your inquiry and explanation of procedures...

Anterior and Posterior Labral Repairs
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Anterior and Posterior Labral Repairs

April 13, 2023 Question: Our surgeon documented anterior inferior labral repairs and then documented posterior inferior repairs.  The surgeon wants to report 29806 x 2 and I do not believe that is correct.  Will you assist? Answer: Thank you for your question. You are correct in that CPT code 29806 may not be reported twice....

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