November 30, 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 16, 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...
November 2, 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 19, 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 procedures such as skin lesion removal and biopsies in the office. They are counting the total time spent with...
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...
August 3, 2023 Question: I repaired a 12 cm jagged laceration of the midabdomen by undermining 1cm 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...
July 6, 2023 Question: I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the...
June 8, 2023 Question: If the patient is coming in for a skin examination and they have a history of skin cancer, is the complexity of the problem addressed low or moderate. We are having a debate in our office about this. The coders feel it is low when this is the only problem addressed...
May 11, 2023 Question: Can we bill for a simple repair when the surgeon performs Mohs? Answer: An intermediate or complex repair, flaps or grafts may be reported in addition to MMS. The simple repair is included in the procedure and is NOT reported. *This response is based on the best information available as of...
April 13, 2023 Question: We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation. Answer: The procedure note for Mohs Surgery should always contain Indication for procedure Biopsy results Location of lesion Number of lesion(s) Size of the lesion(s), Number of...
