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...
June 8, 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...
May 25, 2023 Question: My plastic surgery saw a patient who sustained an approximately 40% total body surface area burn in a fire. He has previously undergone excision and allograft placement of his extremities. He now came back for removal of the eschar that remains present on his torso and bilateral thighs. The total area...
May 11, 2023 Question: My coder says I cannot bill for taking the patient back to the OR to repair a post-op hemorrhage during the global period. She says that all complications are included in the payment for the initial surgery. Is that correct? Answer: No, that is not the case. You may bill for...
April 27, 2023 Question: When choosing the level of E/M we are confused about the History and Exam. If we choose a level of E/M based on time, does this time count toward total time, or is it only time spent on MDM? Answer: When choosing a level of E/M based on time, CPT identifies...
April 13, 2023 Question: What Modifier do I use when I have to take the patient back to the operating room to repair a post-operative hemorrhage?. My coder told me that complications are included in the payment for the original surgery. But one of my colleagues told me I can bill for the repair during...
