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 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...
November 2, 2023 Question: We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Then on Wednesday morning our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M code into the EHR. The date of service is the date...
October 19, 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...
October 5, 2023 Question: When acting as an assistant surgeon, should I dictate a separate operative note? Answer: No. In a scenario with a primary and assistant surgeon, only the primary surgical dictates the operative note. Importantly, in that note, the specific role of the assistant must be documented. This should be more specific then,...
August 17, 2023 Question: Our physicians’ defaults 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), and performs procedures such as nasal endoscopies, debridement’s laryngoscopes etc. in the...
August 3, 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...
July 20, 2023 Question: I repaired a 12 cm jagged laceration of the midabdomen by undermning1cm to release the skin edges. Due to the length of the laceration and potential wound tension concerns, I closed the laceration in layers and retention sutures are used. What procedure code should I report? Answer: Good question. Because Undermining...
July 6, 2023 Question: A 24-year-old male is seen in our office for gynecomastia. My physician did a bilateral resection of the glandular component and liposuction of the fatty components of his defect. I am new to coding for plastic surgery and not sure how to code this. Can you help? Answer: Of course. The...
June 22, 2023 Question: I need some guidance. A general surgeon did a left mastectomy four months ago for a patient who had breast cancer. My plastic surgeon did a breast reconstruction yesterday. What diagnosis code do I use? Answer: You would report 3 codes, the encounter for breast reconstruction following mastectomy Z42.1, Personal history...
