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    Wiki 99497 & 99498

    Please see the CMS fact sheet MLN909289. There is a table on page 4 showing that CMS applies the CPT midpoint rule.
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    Wiki G2211 description on patient statements

    I don't work directly with practices and I have not seen any messaging from Medicare to beneficiaries to explain the new charge. The short descriptor from CMS is "Complex e/m visit add on." However, you might consider something like, "Longitudinal care resource add-on" as the term "complex"...
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    Wiki Searching for diagnosis code

    If you look up hair tourniquet, you are directed to constriction, external, by site which leads to external constriction of the clitoris and directs to S30.844A External constriction of vagina and vulva, initial encounter. R10.2 describes pain in the perineum. Hope that helps. Cindy
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    Wiki 31615

    You are correct that 31615 describes a complete bronchoscopy. 31575 appears to be more appropriate. You can see a related question and answer in the December 2020 CPT Assistant newsletter. Hope that helps. Cindy
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    Wiki Annual Physical Exam & renewal of birth control

    See coding advice from ACOG here, https://www.acog.org/education-and-events/publications/larc-quick-coding-guide/em-services-code-only. This is specific to long-acting reversible contraceptive but the same would apply to prescription of other forms of contraception. Hope that helps, Cindy
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    Wiki 69210-RT and 69200-LT

    Ear wax is not a foreign body. Removal of non-impacted cerumen is not separately reported from the service requiring the clearance (eg, office visit). I hope that helps. Cindy
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    Wiki 83036 A1c Denials

    No easy answer on this one. You would need to access the CIGNA plan's policy for A1c testing to see what diagnosis codes (E11.65 should be good.), frequency of testing (usually 90 days), etc. are covered by the plan. If no answers are found there, it may be necessary to contact provider services...
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    Wiki JZ Modifier

    For now, I suggest that you follow any instruction from the individual payer; some are not requiring JZ at all. Some may exempt vaccines based on the Medicare policy that exempts the vaccines covered under Medicare Part B. Medicaid plans will likely issue policies on the appropriate use based on...
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    Wiki RX REFILLS

    This answer from Medicare Part B Administrative Contractor, First Coast Service Options, may state it best. "E/M FAQ -- What constitutes prescription drug management? Q. During an evaluation and management visit, what constitutes "prescription drug management?" A. "Prescription drug management"...
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    Wiki Vaccine Supervision

    To verify that no supervision is required, see the Medicare Claims Processing Manual (cms.gov/manuals online only manuals 100-04, Chapter 12, section 10.1.2) for the following. "Effective for services furnished on or after May 1, 1993, the influenza virus vaccine and its administration is...
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    Wiki Flu shot Medicare

    The list on this page, https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/vaccine-pricing, will give you the codes for the currently recommended vaccine products. As previously answered, report G0008 for the administration of the vaccine. I don't remember for certain but think...
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    Wiki Question 2023 Inpatient/ Observation coding

    If any physician or other qualified health care professional in the same specialty and same group has provided face-to-face care at the hospital, the patient is established when seen in the office. It is not the site of service that matter but whether any professional service has been provided...
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    Wiki P00.82 vs Z20.818

    Code P00.82 (newborn affected by maternal colonization) is reported based on the observation for the suspected condition until it is ruled out (eg, no signs or symptoms at 24 hours) and then code Z05.1 (observation and evaluation of newborn for suspected infectious condition ruled out) would be...
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    Wiki How to code, administration of Survanta (NICU)?

    Hi, look at code 94610 but note that this is bundled into daily critical care. The code is reported per dosing episode. I hope that helps. Cindy
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    Wiki Congenital Diaphragmatic Hernia Non-neonate

    While the congenital diaphragmatic hernia is usually repaired early in the neonatal period, there are codes for the non-traumatic paraesophageal hernia repair (43332-43337 for open approaches) that may describe the procedure performed. I did see a case report of a child who was diagnosed at age 4.
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    Wiki Modifier 25 and X Rays in MD office Setting

    I agree. The E/M instructions are clear that tests for which the physician is reporting a code for the interpretation and report do not count toward the amount and/or complexity of data to be reviewed and analyzed so there is no overlap of the E/M and the interpretation and report of the x-ray...
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    Wiki Do I bill Transitional Care or Home Visit?

    The answer depends on whether your physician/provider met all of the requirements for transitional care management (eg, contact within 2 business days of discharge, visit within 7 or 14 days) and the extent of the visit performed in the parking lot (ie, did it involve moderate or high complexity...
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    Wiki Pediatric Complex Condition Coding

    You might find some helpful resources at https://www.aap.org/coding. The Coding Fact Sheets cover a variety of topics.
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    Wiki Chart request, can a provider say no and refuse.

    It is important to consult a health care attorney prior to refusing. HIPAA cannot be used as a reason for not providing the records. Under HIPAA, physicians can release PHI to payers for health care operations which include care coordination (eg, offering case management or other supportive...
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    Wiki Incision and Drainage of left ring finger

    I agree with 26080 as long as the joint space was entered versus tissues above the joint.
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    Wiki Pediatrics - need advice

    This varies by state as does the age of majority. Check with your state medical society or medical liability company.
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    Wiki midpoint

    It is correct to use the midpoint rule for codes 99401-99404. CPT Assistant used code 99401 as an example for use of the midpoint stating that 8 minutes were required to report 99401. The midpoint applies whenever there is no other time instruction in the prefatory instructions or code...
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    Wiki Using E10 and E11 together

    Hi, The combination of type 1 and type 2 diabetes also referred to as type 1.5 or double diabetes is reported with a code from category E13 per Coding Clinic. Cindy
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    Wiki ICD-10 Code Used for Discussion About COVID-19 Vaccine

    At present, there is no specific code for immunization counseling without administration; report Z71.89 (other specified counseling). CMS has indicated in the proposed rule for inpatient prospective payment in 2022 that a code (Z71.85) will be added for specifically reporting immunization safety...
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    Wiki Finger Laceration With Avulsion of Nail - Can I Assign CPT Code for Both?

    The answer is not straightforward. I think you have to look at whether there was one or two separate repairs (repair of nail bed with adsorbable sutures and repair of nonadjacent skin with non-adsorbable sutures). I also thought about this more and you may want to check the individual payers...
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    Wiki Finger Laceration With Avulsion of Nail - Can I Assign CPT Code for Both?

    The procedures would have to qualify for a modifier such as XS, separate structure, as NCCI bundles the skin repair to the nail repair. Hope that helps. Cindy
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    Wiki Newborn admit/discharge

    If the physician provides initial normal newborn care on the date after the day of birth and on that same date discharges the newborn to home, report same date admit and discharge services, 99463. Consider the date the physician provides the service not the date of birth. Does that help? Or is...
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    Wiki Maternal Depression in Pediatric Coding

    Unless the physician is creating a chart for the mother and addressing the positive screening (eg, counseling the mother and coordinating follow-up with another provider), the depression screening is reported with the routine child health exam code (Z00.121 or Z00.129) and code 96161...
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    Wiki Question for CPEDC's

    I haven't done much so far this year so have not had difficulty. Do you have access to the coding newsletters from the American Academy of Pediatrics? The quizzes for each issue are worth 0.5 CEUs. I am not sure how you can determine which local chapters are having meetings that are approved for...
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    Wiki Help with E/M Assisted Living Facilities 99324-99328

    As noted, the Medicare rules are different for SNF visits but as a point of clarification, it is not correct that the NP or PA cannot provide and report an E/M service that takes place before the physician's "initial visit." The CMS guidance is to report medically necessary E/M visits to a...
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    Wiki Transitional Care Management

    CPT is clear that the first face-to-face visit is part of the TCM service and not reported separately. Also, the care provided during the TCM is supposed to be of moderate to high complexity. To get an idea of the kind of physician work that is included in TCM, the TCM RVUs are somewhere between...
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    Wiki Critically ill newborn coding for time?

    Your physician is the transferring physician so time-based codes are appropriate per CPT as long as the receiving physician at the University hospital is in a different group practice or of a different specialty. The guidelines for the neonatal codes say that when critical care services are...
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    Wiki Prolonged Office Visits/Change 2021 99415, 99416

    These codes for prolonged clinical staff time remain in 2021 but the time is calculated using the times assigned to the revised office E/M codes. Time begins 30 minutes after the highest total time in the time ranges of the code descriptions. For example, the highest time for 99214 is 39...
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    Wiki Newborn Circumcision

    You might want to check the health plan's payment policy for circumcision. Some cover only medically necessary circumcision. If the plan covers routine circumcision, you might try adding the code for the premature birth (e.g., P07.3- to gestational age at birth). I hope that helps a little. Cindy
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    Wiki 2021 E/M Guidelines - Cat 2 Ordering Unique Tests for labs

    That is correct. Each order or review of results of a test represented by a unique CPT code is counted as long as the test/study was not performed and reported by the physician. There is no requirement that the combination of 3 unique tests come under different bullets (e.g., no requirement that...
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    Wiki 2021 MDM table

    Yes. Ordering 2 distinct tests (each represented by a separate CPT and not a component of the other) meets the requirements for low amount/complexity of data. However, you cannot count any separately reportable test or study performed during the encounter. Cindy
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    Wiki 2021 E/M Guideline Changes

    Important - The AMA says you cannot count any test or study that could be separately reported by the physician (ie, has a CPT code) toward the amount and/or complexity of data. I apologize for the wrong information that I gave on this, it was based on advice that came from the AMA but may have...
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    Wiki 2021 E/M Guidelines - Cat 2 Ordering Unique Tests for labs

    IMPORTANT CORRECTION to my post above. The AMA says you cannot count any test toward your data if a CPT code exists for the test and you could separately report it. An organization that I work with had previously receiving conflicting advice that the determining factor was whether or not a test...
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    Wiki 2021 E/M Guidelines - Cat 2 Ordering Unique Tests for labs

    Each unique test is counted once (either order or review). CPT states, "Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter." Laboratory test orders or results are counted whether performed...
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    Wiki Independent Historian??

    If you have not already seen it, the AMA has answered your question (agreeing with you) in the November issue of CPT Assistant. The independent historian is someone who give history that the patient cannot give either completely or at all. Cindy
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    Wiki Professional component for 96127

    If you look at the Medicare Physician Fee Schedule, the work RVUs are zero and the PC/TC indicator in column N is 3. 3 = Technical component only codes. This indicator identifies stand alone codes that describe the technical component (such as staff and equipment costs) of selected diagnostic...
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    Wiki Cpt code for BinaxNow rapid Covid 19 Antigen card

    I believe that is 87811, Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]). Cindy
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    Wiki Pediatric Well visits with immunizations

    The ICD-10-CM tabular list includes a code first instruction under code Z23 that instructs to code first any routine childhood examination. This indicates that Z23 is not the first-listed code when provided in conjunction with a routine child health examination. The tabular list also includes...
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    Wiki Venipucture Coding

    You might reference Chapter 16 Section 60.1.1 of the Medicare Claims Processing Manual and/or payment policies posted by some of the health plans in your area. As others have said, there have probably been some denials in the past. I do feel that there should be sufficient documentation to...
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    Wiki CMS Policy for new 2021 E/M changes

    Choose the link to the rule that is at the bottom of the page under related links. The rule is a big PDF file but you can find the information you need starting on page 50122. Cindy
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    Wiki Laceration Repairs

    Were the lacerations of the lip through the full thickness of the lips? If so, look to code 40652 or 40654. There is a November 2016 CPT Assistant article that provides some information on coding for lacerations of the lip. I hope that helps. Cindy
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    Wiki Professional component for 96127

    Code 96127 has no physician work value. This code represents the practice expense of obtaining a structured assessment, scoring, and documentation of the instrument used and score. The physician's interpretation of the score in light of the patient presentation is part of an evaluation and...
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    Wiki CMS Policy for new 2021 E/M changes

    Hello, You can find the proposed rule for the Medicare Physician Fee Schedule at https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1734-p where CMS confirms their intent to adopt the new CPT guidelines as stated in the final rule for...
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    Wiki Superbill

    Hi Nikki, If your physician is a member of the American Academy of Family Physicians (AAFP), you can get a lot of resources from AAFP. You can get a superbill template (Excel spreadsheet) from the AAFP's Family Practice Management magazine tool box (log-in and password required to download)...
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    Wiki Chemical cauterization

    CPT Professional edition has this instruction for 1750, (Do not report 17250 when chemical cauterization is used to achieve wound hemostasis). 17250 is a destruction code intended for destruction of proud flesh/granulation tissue. Destruction means the ablation of benign, premalignant or...
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