August 17, 2023 Question: There is a product called CTM Boost that is being marketed as a regenerative medicine injection covered by insurance under this code, C1762. Have you seen this and are any amniotic or regenerative products covered by Medicare or private payors? Is this an acceptable code for office use? Answer: Thank you...
Category: Orthopaedics
Using a Scribe
August 3, 2023 Question: I would like to know if it is compliant for the doctor to make corrections or additional comments on the note written by the scribe? For example, the note is written by the scribe, but at the end of the day the doctor reviews the note and makes correction if he...
Internal Brace for ACL Reconstruction
July 20, 2023 Question: We have a surgeon who is planning to perform an ACL procedure using the InternalBrace TM Technique. The surgeon is asking if she would still report CPT code 29888, use a modifier 52, or an unlisted code. Are you able to advise? I do not have an operative note to send....
Radiology Reports
July 6, 2023 Question: Earlier this year, I attended an education session (not provided by KZA) where radiology reports were discussed. We have been going to KZA courses for many years and have the workbook pages with the history of the requirement and definition change for reports. We were confident we knew the documentation requirements...
Syndesmosis Repair
June 22, 2023 Question: I coded a case for one of our surgeons where he did an ORIF of a distal tibia/fibula fracture (Pilon) and syndesmosis repair and documented a separate diagnosis to support each procedure. I recommended CPT code 27828 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon...
POS for Hospital Services
June 8, 2023 Question: We are wondering if you can help address a discussion in our office related to the coding rule changes for hospital services. CPT instructs to report 99221-99223 (inpatient hospital/observation) and 99231-99223 (subsequent hospital/observation) for both inpatient and observation services. Our hospital does not have a dedicated outpatient observation area; all patients...
Is an Annular Repair Separately?
May 25, 2023 Question: Our physician stated he was told at his prior hospital that he could report an annular repair with a discectomy. We have told him this was inclusive but he is asking us to contact KZA. Is the annular repair reportable in addition to the discectomy code? If yes, what CPT code...
Retrocalcaneal Bursectomy
May 11, 2023 Question: Our surgeon performed a repair of an Achilles tendon, excision Haglund’s deformity of the calcaneus and retrocalcaneal bursectomy. Are we able to code the bursectomy in addition to the repair and excision of Haglund’s? Thank you in advance for your assistance. Answer: Thank you for your inquiry and explanation of procedures...
Shared Visits in the Hospital for Medicare
April 27, 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...
Anterior and Posterior Labral Repairs
April 13, 2023 Question: Our surgeon documented anterior inferior labral repairs and then documented posterior inferior repairs. The surgeon wants to report 29806 x 2 and I do not believe that is correct. Will you assist? Answer: Thank you for your question. You are correct in that CPT code 29806 may not be reported twice....