August 11, 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...
Category: CC-Otolaryngology
2021 Evaluation and Management Codes: Is a History Required?
July 28, 2022 Question: My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me. Answer: You are wise to ask because that’s not exactly true. It is correct that the History will no longer be...
Modifiers on Unlisted Codes. Yes or No?
July 14, 2022 Question: Can I use modifiers on an unlisted code? What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code. Answer: There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers...
Confusion Regarding the 2021 E/M Guidelines
June 30, 2022 Question: The guidelines that came out in 2021 for E/M services is for all types of E/M services, right? Answer: No. The 2021 E/M guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the 1995/1997 guidelines for all other E/M services, even consultations in the office. *This...
Incident-to Requirements for Medicare
June 16, 2022 Question: Thank you so much for all the information you gave out in Chicago at the KZA Convention. We always have great take-a-ways when we leave there. I do have a question for you regarding incident-to billing for Medicare. One of my physicians is stating that her attorney told her being “under...
Coding for a Hospital Visit
June 2, 2022 Question: I was at your conference this past weekend and I was wondering if you could clarify something for me. When a physician sees a Medicare patient in the hospital, and it is their first time seeing the patient however they are NOT the admitting physician, they can only bill a subsequent...
Billing Additional Pre-op Visit
May 19, 2022 Question: Since we have to bring the patients back in for COVID testing and H&P for Joint Commission, can we bill for this visit even though it’s another pre-op visit? Answer: Yes, since the original surgery was canceled and is now under consideration for rescheduling due to the pandemic and needs to...
Vocal Fold Augmentation Injections in the Office
May 5, 2022 Question: What code do I use for a vocal fold injection for augmentation in the office? Can I also bill for the injection material? Answer: Good questions! The correct code is 31574, Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral when performed via flexible laryngoscopy. If you’re in place of...
Inpatient E/M Coding
April 21, 2022 Question: I did an inpatient consultation and coded 99253 (non-Medicare). I did not need to follow the patient so I signed off. They asked me to re-consult a week later. What is the code for a re-consult? Answer: There are no specific E/M codes for an inpatient re-consultation. You’ll use the subsequent...
Adjacent Tissue Transfer
April 7, 2022 Question: A few years ago I was at your coding workshop in Chicago – you were great, Kim! I remember discussing the adjacent tissue transfer or rearrangement codes and you said we need a size dimension to code for CPT 14040 or 14041 or any of the ATT codes. Do you have...