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…

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…

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…

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…

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…

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…

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:…

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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…

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…

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…

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…

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…

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…

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…

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?…

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…

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…

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…

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…

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.…

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…

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,…

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…

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?…

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…

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…

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.…

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…

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…