We are in an academic setting and I have a question about a specific service performed when a resident was involved on a Medicare case. I was reading notes for a patient who presented to the emergency room (ER) and was admitted to the Orthopaedic Attending physician’s service. The notes by the resident in the ER indicate that the Attending Physician was contacted, though the Attending did not see the patient in the ER. The resident documented the findings and discussion with the attending via the telephone; documented specific orders by the Attending for care provided while the patient was in the ER, including the admission to the Orthopaedic Service. The Attending Physician saw the patient the next day and documented the visit. My question is, can I bill for an E&M service for the telephone discussion with the Attending Physician even though the Attending did not see the patient in the ER? The Attending Physician stated that unless something has changed, the discussion with the resident is not a billable service for him.
Category: Coding Coach
ICD-10: Procedural Coding System vs. CPT Codes
Now that ICD-10 is going to happen I’m starting to look into it a bit more. I see there is a procedural coding system component. Are we going to have to use that instead of, or in addition to, CPT?
ICD-10: Procedural Coding System vs. CPT
Now that ICD-10 is going to happen I’m starting to look into it a bit more. I see there is a procedural coding system component. Are we going to have to use that instead of, or in addition to, CPT?
TLIF
I have an operative report where the neurosurgeon performed L5-S1 minimal invasive transforaminal lumbar interbody fusion (TLIF) with L5/S1 and an instrumented fusion (pedicle screws/rods). He did a far lateral transforaminal approach to disc space with left L5/S1 facetectomy and discectomy. He also placed a PEEK cage for the interbody arthrodesis packed with morselized allograft and autograft.
2015 Changes to 37215, Carotid Stent, Coding
I heard there was a revision to 37215, carotid stent with embolic protection. What is this exactly?
Claw Toe
We are having some debate about whether CPT code 28285 (hammertoe repair) would be appropriate for fusion of a claw toe? The claw toe is the DIP joint; the hammertoe is the PIP joint. However, code 28285 does not specify which interphalangeal joint is corrected. Should we report 28285 or an unlisted code?
CPT 92547: Use of Electrodes
What happened? I used to bill 92547 - use of electrodes during electronystagmography – with 5 units and now Medicare will pay only one unit.
Nipple Tattoo in Breast Reconstruction
Is it OK to charge the tattooing if it is done a few weeks after the nipple repair/reconstruction (19350)?
Anterior/Posterior Spine Procedures: What Modifier Should I Use?
What modifier do you suggest I use when we do anterior/posterior spine procedures on the same patient at the same operative session on the same day? My coder thinks we should use modifier 58 (staged) but I remember you saying, at AANS coding courses, not to use modifier 58. Please help.
Carotid Stenting and Diagnostic Angiograms
I was told that no diagnostic angiogram can be billed with a carotid stent. Is this true?