Category: Coding Coach


Injection Code 96372, Is This Correct?

I am new to orthopaedic coding, having just left a Family Practice group after many years. The surgeon said he did an injection to the flexor tendon sheath of the right index finger. I want to verify that CPT code 96372 is correct for the injection. I am very familiar with reporting the J codes for the drugs.


AV Graft Coding

In order to treat occlusion of an AV graft, I had to angioplasty both the venous portion and the arterial anastomosis. Can I report both 35475 for the arterial angioplasty and 35476 for the venous angioplasty?


E&M Selection Based on Time

Our surgeon saw a patient in the office following a shoulder MRI. In the visit, the surgeon documented, “I had a very long face-to-face discussion with the patient today regarding their shoulder MRI. I spent over 20 minutes in the exam room discussing the results of the scan, reviewing the MRI with the patient, discussing the findings, pathology of the disease process and discussing operative versus non operative management. The patient has chosen to start first with physical therapy but understands that due to the pathology at this time, surgery may be required in the future.” The surgeon has stated that this visit should be based on time because there was no medical necessity to repeat all the history and exam information as nothing had changed since the prior visit. In looking at the note, I do not believe the documentation requirements are met to select a code based on time. Can you please advise?

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Coding Coaches