August 25, 2022 Question: My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me. Answer: You are wise to ask because that’s not exactly true. It is correct that the History will no longer be...
August 11, 2022 Question: Can I use modifiers on an unlisted code? What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code. Answer: There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers...
July 28, 2022 Question: When billing for the muscle flap codes 15733, 15731 etc., can we also code for the surgeon’s cleaning and prepping by debridement before closing the wound with a facial flap? Answer: Yes, the surgical prep codes (15002-15005) may be reported with those flap codes as long as the surgical prep service...
July 14, 2022 Question: We have a new plastic surgeon who will start doing craniosynostosis surgery with a pediatric neurosurgeon. Will this be co-surgery using modifier 62? Answer: Potentially yes. It will depend on which surgeon does what part of the procedure. All the craniosynostosis codes (61550 – 61559) accept modifier 62 so if both...
June 30, 2022 Question: Can I bill an office visit in the global period if the diagnosis is different from why I did the original procedure? Answer: Yes, as long as the diagnosis is not for a related issue (e.g., complication from the original procedure). The documentation must be clear that the condition is unrelated...
June 16, 2022 Question: I’ve heard you say to wait for the pathology report in order to bill for the skin lesion excision codes 114xx (benign) and 116xx (malignant)? What if I have a biopsy report – do I still need to wait? Answer: Good question – no you do not need to wait if...
June 2, 2022 Question: We are going to be doing bilateral carpal tunnel procedures on a patient – the right side will be done first then the left will be done 8 weeks later. Should I use modifier 58 (staged procedure) on the 2nd procedure? Answer: Actually, it’s best to use modifier 79 (unrelated procedure...
May 19, 2022 Question: I had to take a patient back to the operating room 6 weeks after breast reduction to excise a small dehiscence and close the wound. Can I bill for this? Answer: Yes, you may bill for the service and you’ll need to use modifier 78 (return to the OR for a...
May 5, 2022 Question: One of our spine surgeons has asked me to help with an upcoming case. The patient is obese and has had multiple prior spine procedures. The spine surgeon would like me to close using bilateral paraspinal muscle flaps. How do I code the procedure and will I even get paid? Answer:...
April 21, 2022 Question: We are having a debate on whether to use a mastectomy code or breast reduction code for “top” female-to-male procedures. What’s your advice? Answer: Unfortunately, we do not have a specific CPT code(s) for these procedures as the existing codes were not written with these procedures in mind. Our advice is...
