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Removal of Eschar
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…
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…
Bone Anchored Hearing Implants
May 25, 2023 Question: What CPT code would I report for implanting a bone anchored osseointegrated implant with a magnetic transcutaneous attachment outside of the mastoid? Answer: In 2023 three new CPT…
Secondary Payor Doesn't Recognize Consultations
May 25, 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,…
Facet Fusion
May 25, 2023 Question: The neurosurgeon documents a placing a cervical “facet implant or intrafacet implant “ with bone graft. Is this coded as 22600, cervical arthrodesis? Answer: No. This…
What Does “Separate Procedure" Mean in a CPT Code Description?
May 11, 2023 Question: What does “separate procedure” mean when it follows a CPT code description? Answer: Per CPT : Some of the procedures or services listed in the CPT…
POST OP Hemorrhage Repair
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…
Vessel Exploration
May 11, 2023 Question: What code is used to make an incision over the femoral artery to evaluate for injury, and explore it without any repair? Answer: Use code 35703,…
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…
E/M Coding Based on Time
May 11, 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…
Billing for a Repair immediately Following Mohs Surgery
May 11, 2023 Question: Can we bill for a simple repair when the surgeon performs Mohs? Answer: An intermediate or complex repair, flaps or grafts may be reported in addition…
Code +15777 for Placement of a Non-biologic Implant. Is this the Correct Code?
May 11, 2023 Question: I placed a non-biological implant for abdominal soft tissue reinforcement. Can this be coded as +15777? Answer: No. Code +15777 is reported specifically for a biological…
Placing Methylmethacrylate around Pedicle Screws
May 11, 2023 Question: The surgeon placed methylmethacrylate around the pedicle screw in a spine surgery. How is this coded? Answer: Placing methylmethacrylate to reinforce the instrumentation is included in…
E/M Coding Based on Time
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…
Coding Thrombolysis Infusion and Stent
April 27, 2023 Question: A patient with a clot in the femoral artery had overnight infusion of thrombolytics. When the catheter was removed the next day, the doctor place a…
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…
Allergy Injections and E/M on the Same Date
April 27, 2023 Question: We routinely bill allergy an E/M service when the patient comes in for allergy shots. Is that acceptable? Sometimes we bill 99211 if the nurse gives…
Reporting a Cholecystectomy and an Umbilical Hernia at the Same Operative Session
April 27, 2023 Question: If a patient undergoes an open cholecystectomy and has a reducible umbilical hernia repaired during the same operative session, through separate incisions, can both be reported? …
Laser Interstitial Thermal Therapy (LITT) Coding
April 27, 2023 Question: When using LITT treatment, can the neuronavigation and headframe placement be billed separately? Answer: No, neuronavigation, 61781 and headframe placement, 20660 are included and may not…
Secondary Payor Doesn't Recognize Consultations
April 13, 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,…
Post Op Hemorrhage Repair
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…
E&M Coding Based on Time
April 13, 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…
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…
Allergy Treatment Coding
April 13, 2023 Question: What CPT code do I use to report a vial test? Answer: There is no CPT code, nor should you charge, for a “vial test.” This…
Mohs Surgery Question
April 13, 2023 Question: We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation. Answer: The…
Reporting a Cholecystectomy with a Cholangiogram
April 13, 2023 Question: If a cholangiogram was performed by the surgeon during a cholecystectomy, but the radiologist interprets it, is 47563, Laparoscopy, surgical; cholecystectomy with cholangiography still appropriate? Answer:…
Laser Interstitial Thermal Therapy (LITT) Coding
April 13, 2023 Question: I’m using LITT for epilepsy treatment. Answer: The codes are 61736 Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging…
Wound Debridement
March 30, 2023 Question: What CPT code would you use for a wound debridement when the operative notes says the wound will heal by secondary intention. Do you use a…
Secondary Payor Doesn't Recognize Consultations
March 30, 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,…
Costochondral Injection
March 30, 2023 Question: We saw a patient who presented with chest pain and the physician diagnosed costal chondritis and the administered an injection into the costochondral junction. We are…