Category: CC-Otolaryngology

Cautery of the Turbinates
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Cautery of the Turbinates

February 15, 2024 Question: What CPT code do we report for cautery of the turbinates? Answer: This is based on the documentation CPT code 30801 (ablation, the soft tissue of inferior turbinate’s, unilateral or bilateral, any method [e.g., electrocautery, radiofrequency ablation, or tissue volume reduction]; superficial) CPT 30802 (ablation, the soft tissue of inferior turbinate’s,...

Surgery
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Surgery

February 1, 2024 Question: What is the difference between CPT code 31267 vs 31256? Answer: CPT code 31267 (nasal/sinus endoscopy, surgical, with the removal of tissue from maxillary sinus) instead of code 31256 (nasal/sinus endoscopy, surgical, with maxillary antrostomy). For coders to report code 31267, the physician must remove ‘tissue’ (e.g., polyps, fungus ball, mucocele)...

Time Reporting for E/M Levels
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Time Reporting for E/M Levels

December 28, 2023 Question: Is it best practice to bill 99202-99215 based on time only? Answer: CPT Codes 99202 to 99215, history and physical examination will no longer be a key factor in determining your level of coding. Instead, coding will be dependent on: Levels of medical decision making applied during the service OR Total...

Time
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Time

December 14, 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...

Date of Service
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Date of Service

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...

Diagnosis Coding Excludes 1 Codes
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Diagnosis Coding Excludes 1 Codes

November 16, 2023 Question: Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes...

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

October 19, 2023 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 procedures such as nasal endoscopy, sinus debridement, laryngoscopy, etc. in the office. They are counting the total time spent with the...

Modifier Order on CMS Claim Form
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Modifier Order on CMS Claim Form

October 5, 2023 Question: We are submitting a hospital claim form with the modifier 25 and FS modifier. We are unsure which modifier to list first. What is your recommendation? Answer: Thanks for contacting KZA and remembering to use the FS modifier for shared services provided in the hospital. KZA recommends placing the modifier 25...

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