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Time Reporting for E/M Levels

Time Reporting for E/M Levels

November 30, 2023 Question: My physician is billing office visits 99202-99215 based on time only.  Is this best practice? Answer: The E/M services 99202-99205 are based on either medical decision…
Procedure Question

Procedure Question

November 30, 2023 Question: When we take the patient to the OR to debride a wound or burn using Versajet what is the best CPT code to report? If we…
Stab Phlebectomies

Stab Phlebectomies

November 30, 2023 Question: When a provider preforms less than 10 stab phlebectomies what is the comparison code? Answer: I would recommend using CPT 37999 for the stab phlebectomies. Make…
Established Patient: New Injury and Injection

Established Patient: New Injury and Injection

November 30, 2023 Question: We have a major hip and knee practice. We frequently see patients back for repeat injections; typically, we do not report the E&M, and report the…
Date of Service

Date of Service

November 30, 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…
Time

Time

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…
Appendectomy with Cecum Resection

Appendectomy with Cecum Resection

November 30, 2023 Question: As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy? Answer:…
Shared Visits in the Hospital for Medicare

Shared Visits in the Hospital for Medicare

November 16, 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…
Time

Time

November 16, 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…
Ablation of Truncal

Ablation of Truncal

November 2, 2023 Question: How often can you use the add on codes for mechanochemical ablation of varicose veins? Answer: Use add-on code(s) 36474,36476, 36479 or 36483 for additional veins…
Established Patient Encounter: Is Modifier 25 Supported?

Established Patient Encounter: Is Modifier 25 Supported?

November 16, 2023 Question: An established patient presents to the office for return of knee pain six months after the last injection to the same knee. The patient relates no…
Diagnosis Coding Excludes 1 Codes

Diagnosis Coding Excludes 1 Codes

November 16, 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…
Date of Service

Date of Service

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…
Time Reporting for E/M Levels

Time Reporting for E/M Levels

November 16, 2023 Question: Is it best practice to bill 99202-99215 based on time only? Answer: CPT Codes 99202 to 99215, history and physical examination will no longer be a…
Procedure

Procedure

November 16, 2023 Question: When two surgeons work together as primary surgeons performing distinct part(s) of the procedure, and each surgeon reports his/her distinct operative work, what modifier is appended?…
E/M Coding Based on Time

E/M Coding Based on Time

November 2, 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…
Diagnosis Coding Excludes 1 Codes

Diagnosis Coding Excludes 1 Codes

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…
Date of Service

Date of Service

November 2, 2023 Question: We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Then on Wednesday morning our attending physician…
Time Reporting for E/M Levels

Time Reporting for E/M Levels

November 2, 2023 Question: Is it best practice to bill 99202-99215 based on time only? Answer: CPT codes 99202 to 99215 no longer require that the History and Examination be…
POEM Procedure Coding Part 2

POEM Procedure Coding Part 2

November 2, 2023 Question: I know the POEM procedure, is reported with code 43497, Lower esophageal myotomy, transoral (ie,perioral) endoscopic myotomy (POEM). One of our surgeon does the G-POEM procedure.…
Coding Percutaneous Rods and Screws: Part 3

Coding Percutaneous Rods and Screws: Part 3

November 2, 2023 Question: If percutaneous rods and screws are placed without a parent or primary code, for example as a staged procedure a different day after an ALIF or…
Secondary Payor Doesn’t Recognize Consultations

Secondary Payor Doesn’t Recognize Consultations

November 2, 2023 Question: We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However,…
E/M Code and Injection Code: Can We Bill Together?

E/M Code and Injection Code: Can We Bill Together?

November 2, 2023 Question: We have a new patient presenting for evaluation of new elbow pain after a fall. The provider documented a full history and exam then ordered and…
Modifier Order on CMS Claim Form

Modifier Order on CMS Claim Form

October 19, 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?…
E&M Coding Based on Time

E&M Coding Based on Time

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…
Diagnosis Coding Excludes 1 Codes

Diagnosis Coding Excludes 1 Codes

October 19, 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…
Coding for TCAR

Coding for TCAR

October 19, 2023 Question: How is the TCAR procedure reported? Answer: Transcarotid Artery Revascularization (TCAR) is a minimally invasive procedure that can clear blockages and open a narrowed cervical carotid artery.…
POEM Procedure Coding Part 1

POEM Procedure Coding Part 1

October 19, 2023 Question: How is the POEM procedure reported? Answer: The POEM procedure, Peroral Endoscopic Myotomy, had a new code in 2022: 43497, Lower esophageal myotomy, transoral (ie, peroral…
Coding Percutaneous Rods and Screws: Part 2

Coding Percutaneous Rods and Screws: Part 2

October 19, 2023 Question: What if we the neurosurgeon places percutaneous screws and rods (no posterior fusion/bone graft) as the sole treatment for a vertebral fracture. Do we code the…
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Coding Coaches