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    Wiki Removal of Epidermoid cyst

    Can anyone assist with helping me pick a code for this procedure? Below is the documentation that the provider made and the ICD-10 used is, L72.0: Epidermal cyst. It was not sent for pathology, she didn't drain it, and only a part of the membrane was removed. Cyst Removal: Site(s): Medications...
    • carriganm
    • Thread
    • dermatology coding epidermal cyst excision incision and drainage
    • Replies: 2
    • Forum: Dermatology
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    Wiki EMB w/mass found

    Help! I have no idea how to code this one. Endometrial Biopsy: Risks, benefits and indications for endometrial biopsy procedure fully reviewed. Patient questions answered. Informed consent obtained. Speculum placed into vagina. There was a mass of tissue bright red extending out of the cervix...
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    Wiki Zio Patch

    I have a provider who prescribed a Zio patch for a patient and I'm wondering I can count this as prescription drug management? If not, could it be counted as anything with the E/m coding guidelines?
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    Wiki Medial Meniscus

    Can someone please help with how to code for this? I can't find anything applicable on how to code an injection the medial meniscus. The skin was prepped in a sterile fashion with Chloraprep. Local anesthetic was introduced into the area of the injection site's using 27g 1.5 in needle 5 ml 1%...
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    Wiki Diagnosed New Problem

    We often see that a patient comes in for a lab follow-up and the provider dx'd the patient with a new problem. I am trying to figure out how to categorize this in the MDM as it doesn't fall under any of the definitions for number of complexity of problems addressed. Example: Patient had labs...
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    Wiki Patient Write Offs

    Can anyone send me in the write direction on when a family practice clinic can do "courtesy" write off's for patients not related to financial hardship when we are billing insurance? Meaning, we bill patient's insurance, and patient calls in and complains about 'XYZ' and after review of the...
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    Wiki Telemedicine to out of state patients

    I had one of our providers reach out to me and ask, "can I provide a video office visit with a patient who has moved outside of our state?" We are currently in Oregon and we have patients that want to continue care with our providers but they are permanently moving outside the state of Oregon...
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    Wiki Covid prevention diagnosis

    One of our providers is treating a patient with Ivermectin for Covid prevention. The physician used U07.1 which is not accurate since the patient is not currently infected. It does not sound like the patient has been exposed and doesn't currently have any symptoms. He just simply wanted an rx...
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    Wiki Improving conditions- MDM coding

    I have a question on coding the 'Number and Complexity of Problems Addressed' More often than not patient comes in for a follow-up of their chronic conditions and in the assessment it states that patient is seeing improvement and to continue their rx or OTC. How do I code this? There are no data...
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    Wiki 2021 Risk Level

    I am seriously puzzled by the new risk guidelines. As a coder, how do WE determine the risk level if it isn't specifically notated? Or, do we need to require all our providers to specifically list the risk level of the patient in the chart for each encounter in order to appropriately determine...
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    Wiki Paraspinal Neurotherapy???

    Hello- Can someone please advise how they would code this? Dextrose was used, which implies Prolo (M0076) for both the ligament and the paraspinal injections. I have never heard of a paraspinal neurotherapy injection before. Any help would be great. Thank you! Joint/Spine Injection...
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    Wiki Meniscus Injection

    A provider in our office just started doing ligament and tendon injections. What I want to know is how to bill for a medial meniscus injection? I don't feel that the 20550 or the 20610 fit the description for this. In one visit she injected the MCL, LCL, the right knee capsule and the medial...
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    Wiki 20550 or 20551- So confused

    So I work for a family practice facility and one of our practitioners has started doing injections. I am so confused on what the different between a 20551 and 20550 are? Here is an example of one of her chart notes. I think that I am only going to bill 20550 x1 since all 6 injections were all...
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    Wiki Need help with HPI!

    Hello there! I have a provider in our office that I struggle so much with her HPI's. She will list the labs drawn and the results next to them. Occasionally listing meds taken. Below is an example. I have been told that I can't count these as status of 3 conditions because it is out of the...
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    Wiki Calling all auditors! NEED HELP!

    Hello there! I have a provider in our office that I struggle so much with her HPI's. She will list the labs drawn and the results next to them. Occasionally listing meds taken. Below is an example. I have been told that I can't count these as status of 3 conditions because it is out of the...
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    Wiki Counting HPI elements twice

    I have an HPI where the provider states that the rash has spread from her hand to her face and back of her left leg. Can I count each location as a point or do I only get 1 point for this? Thanks for any help.
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    Wiki PST and bladder instillations

    Hello there! I am in need of assistance on how to bill the below procedures... Procedure #1: What CPT and HCPCS am I going to bill? PST: Informed consent given. Pt. placed in dorsolithotomy position. After cleansing patient with iodine swabs, bladder was cathed using a straight cath. 40 cc of...
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    Wiki New patient vs Established patient

    Hello! So my company that I previously worked for has been bought out by a new medical clinic. This means that all the providers NPI numbers have stayed the same but the group Tax ID and the group NPI number have changed. So my question is, for all the patient's that the providers have seen in...
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    Wiki MDM help!?

    I am have a chart note that I am trying to decide which level of MDM I can use. The patient presents with a new problem to the examiner but it has been treated before by a different provider in a different clinic. The problem is recurring so can I count this as a new problem for 3 problem points...
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    Wiki Counting MDM points

    Can you count acute problems as a new problem in the MDM? For example: HPI: Pt presents today with c/o poison oak rash. She has used OTC cortisone and calamine lotion and essential oils. She first noticed it on her right arm on Saturday. She was holding and hugging her sister's dogs who had...
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    Wiki Need help with HPI for and E/M visit

    I am currently coding for a family practice clinic and need some expertise for one of my providers. My provider is constantly just putting the patient's lab results in the HPI and I need to know if I am allowed to count the lab results as the status of 3 chronic conditions? I gave an example of...
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