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  1. J

    Wiki Documentation for 77332-77334

    Hi. I'm new to coding these sets of codes and I did some research but I wasn't able to find what documentation requirements are needed. I was given some notes that include imaging and planning but I wasn't able to pull from the document whether it was simple, intermediate or complex. Is it based...
  2. J

    Wiki Op Note 101

    Thank You!!!
  3. J

    Wiki Op Note 101

    Here the op note. If you don't mind, please share your thought? How should this be coded. Thank you in advance. (I believe I have all the PHI out). PROCEDURE: Robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic sentinel lymphadenectomy...
  4. J

    Wiki Op Note 101

    Thank you for your response. So the provider added ""Ovaries and fallopian tubes, normal-appearing" under the specimen. Do you still think we should not code? I will educated the provider that they need to document it in the procedure description.
  5. J

    Wiki Op Note 101

    Hi, If a provider list that a salpingo-oophorectomy was performed and under the findings, it states "Ovaries and fallopian tubes, normal-appearing" but there is no details of this part of the surgery in the description of the procedure, can we code?
  6. J

    Wiki Number & Complexity of Problems address

    Hi, Needs some thoughts on how you would code Number & complexity of problems for a newborn with contact & exposure to HIV (Z20.6). The patient is being seen in the office for a follow up appointment and the provider is keeping the infant on AZT (prevent and treat HIV/AIDS). The patient's labs...
  7. J

    Wiki Historian

    Hi, Would you accept "Mother is not sure about the sound of the cough, seem dry" as historian by Mom? Does the provider have to state History by or Mom stated? I don't want to be to hard. Thank you in advance.
  8. J

    Wiki Labs performed at office

    Hi, What documentation requirements are need in order to bill for labs in office? It seems like an odd question but we're finding that we usually only have results not how the specimen was obtain (CPT 87426, 86328) or how it was detected (CPT 87880, 87430). Any resource would be greatly...
  9. J

    Wiki Documentation Requirement 87426

    Hi, What documentation requirements are needed for CPT 87426 and 86328? Currently our provider is documenting rapid COVID test negative. Thank you for your assistance.
  10. J

    Wiki Allergy: E/M with Injection

    Hi, I'm new to Allergy and I have a general question. I'm seeing patient routinely come in for immunotherapy injections and quarterly it seem that the provider does a full visit (E/M). I've read that CMS doesn't cover E/M when performed with the injection unless separately identifiable (normal)...
  11. J

    Wiki New Medicare rules for split or shared and critical care, teaching physicians clarified

    Thank you for your help! I have forward the information.
  12. J

    Wiki New Medicare rules for split or shared and critical care, teaching physicians clarified

    I was reading the Federal register (https://public-inspection.federalregister.gov/2021-23972.pdf) page 422 and it's only mentioning 85% not 100% for both providers. Where can I find that the physician will be paid at 100%? Sorry, I'm attempting to respond to an Attending and I'm triple checking...
  13. J

    Wiki New Medicare rules for split or shared and critical care, teaching physicians clarified

    Are payment going to be 85% no matter who if the attending or the NPP performs it?
  14. J

    Wiki CPAP Reading Credit

    Hi, With the 2021 E/M Outpatient guidelines, if the provider order the CPAP machine, can we also count each reading from the machine when the patient returns for they're follow ups? Thank you in advance!
  15. J

    Wiki Teaching Hospital

    Hi, We're a teaching hospital and I'm working with our ER providers on their documentation. I recent reviewed a few notes that were transfer of care between attendings due to shift change. The first Attending added his attestation for the resident but I've notice that the second Attendings are...
  16. J

    Wiki Erector Spinae Block

    Hi Everyone, There's been much debate on what is the correct CPT code to use for Erector Spinae block (ESP). Our providers are stating it should be coded with 64450 but we have found mix article that say use the unlisted code 64999 and there are other articles that say use 64450. Some of these...
  17. J

    Wiki Ultrasound Guidance

    Hi, When an ED Attending performed ultrasound guidance in order to visualize a vein after multiple failed attempts by nurse, what is the correct CPT code? The provider is currently billing 76937 but it's an add on code and no primary code is billed. Someone suggested to code 36410 with 76937...
  18. J

    Wiki CPT 43240- Is removal of Stent included?

    Hi, I was informed that the removal of stents are included in the code for placement of stent. But for some of the procedure (such as 43276), the describes states remove and replacement or even a guideline to state the removal is included in the procedure. One of our GI providers are removing...
  19. J

    Wiki Documentation for Psych Eval

    Hi, I was wondering if anyone has any templates or can help me with information on what common documentation can be added for psych evals. A majority of our Psych notes are being drown grade with level 3 due to the lack of HPI elements. I've been researching for different templates but they...
  20. J

    Wiki Negative Response for HPI Elements

    Hi, I know this question has been asked in the forum but I wanted to see if there was any difference in opinion now. Can we use Negative response for HPI elements? Such as negative for trauma or patient hasn't take any medication. If anyone has any guidelines to support, it would be greatly...
  21. J

    Wiki Heart Transplant- Donor cardiectomy CPT 33940

    Hello, Does anyone have any information on when to bill Donor cardiectomy (CPT 33940)? My providers are preforming the benchwork and heart transplant and we were recently questioned on why we aren't billing for the Donor cardiectomy. I reviewed some of the op notes and they state harvesting was...
  22. J

    Wiki Size of Wound??

    Hi, My provider performed a debridement of necrotic tissue on the muscle. He states in his documentation "The wound was noted to be approximately 50 cm in the caudal cranial direction and 25 cm in the anterior posterior direction; however, there was significant undermining both superiorly and...
  23. J

    Wiki Mitral Clip

    Our provider is coding 33418-Transcatheter mitral valve repair.
  24. J

    Wiki Mitral Clip

    Hi, Our claim scrubber will not let our claim go without the clinical trail modifier & diagnosis. I reviewed the patient's chart and couldn't locate that the patient was on a clinical trail. Is this a given to add the modifier & diagnosis or is there a website I can check to see if the patient...
  25. J

    Wiki Sequencing CPT

    Hi, I'm planing to take my General surgery exam soon and was wondering if there is anyway to know how to sequence the CPT without knowing the RVU? I don't think we're allowed to take fee schedule in the exam with us. If anyone has taken the exam, please provide some insight. Thank You
  26. J

    Wiki Supervised CRNA

    Per Attending, Supervised.
  27. J

    Wiki Supervised CRNA

    Hi, How should we bill for CRNA that was supervised by the Anesthesiologist for a TEE in 2 Room? It Conscious Sedation (QS) but we also have modifier QK, QX for the CRNA. The Attending is attempting to bill under him but should the CRNA have her name under the service provider and also, what...
  28. J

    Wiki Sepsis=Critical Care??

    Hi, I need to understand if sepsis= Critical care. If my provider documents sufficiently, with a time statement can sepsis equal critical care? I have a provider whom seems to think so he writes "Patient was septic, met our code sepsis alert guidelines (similar to a STEMI, stroke alert or...
  29. J

    Wiki DX for Pulmonary Hypertension w/CKD

    Hi everyone, I hopefully have an easy question that I just can't find...... If a patient has Pulmonary hypertension with ESRD, do I code I12.0 and N18.6? I was thinking I27.0 and N18.6. I understand that Pulmonary hypertension is different than regular hypertension but one of our Cardiology...
  30. J

    Wiki Continuing Intensive Care Service 99477-99480

    Hi, I need some direction with the intensive care code (99477-99480). I've read the guidelines but looking at my provider's notes, it seems like the visits are not meeting them. My question is if the patient is a preterm infant with a low birth weight and the providers are supporting the infants...
  31. J

    Wiki Mediastinal Washout & Exploration

    Hi, I'm coding an op note for a patient with an open chest which requires daily washout of the chest. What's the best code for Mediastinal washout and exploration? I was looking at CPT 35820-58 but it seems like it doesn't fit. Should I add modifier 52 for reduce services since there weren't any...
  32. J

    Wiki Swan Ganz vs. Central Line

    Hi, I'm new to Anesthesia and was hoping someone can help me...... My first question is: When you code Anesthesia, is the only document you use to code the Anesthesia record? Or do you use the procedure note from the surgeon? Second Question: What document do I need in order to bill for Swan...
  33. J

    Wiki Initial or Recurrent Ventral Hernia

    Hi, I'm reviewing an op note that doesn't state if the hernia is initial or recurrent. My first thought is to code initial but just checking to see if there are any guidelines that state if not documented we must code recurrent. Please help. Thank You
  34. J

    Wiki Help with CPT for Abscess

    Hi I need assistance with a procedure note. I'm new to surgery and I'm stuck. I don't know if I'm missing something. I'm looking at 49020 for the below procedure but that seems way off. I was thinking off a regular abscess code 10060. I also coded 49084 for wash and 97606 for VAC. Any thoughts...
  35. J

    Wiki Dopamine Challenge

    Hi, I'm covering for our Neurology coder....... One of our providers have asked me how should she bill for a dopamine challenge. I've looked high and low to see if there was anything out there about how other practices are coding this. To my understanding, the patient comes in without taking...
  36. J

    Wiki Temp Pacemaker & ICD replacement

    Hi Can I bill for both an Replacement of ICD and an insertion of a tempoary Pacemaker? We were looking at CPT 33210 and 33249 bundle they are bundling. Any thought? Is there another code that includes everything? Thank You.
  37. J

    Wiki Critical Care Time

    Hi A question was asked in regards to critical care time in the ED. Several physician asked if they should be including any time that they provided support to Medic prior to patient's arrival in the ED? Has anyone run into this and if so, do you have a documentation that will help assist me...
  38. J

    Wiki Cath Coding

    Hi Can someone assist me with CPT code for the following procedure note? I was going with 92928 and 93454 but feels like i'm missing something. Thank You in advance! :confused: RFA and RFV access after modified Seldinger technique by Dr. The RCA was selectively cannulated with a guide...
  39. J

    Wiki Not a Pre-op Visit

    Hi A patient is admitted for abdominal pain and the surgeon send the pt for additional study on the initial visit. Day 2 they made the decision to performed surgery on Day 2. We billed an initial visit on day 1 and a subsequent visit on day 2 with modifier 57 and the procedure. But the initial...
  40. J

    Wiki HCPCS Code for Inhaler

    Hi Does anyone know if we can bill for albuterol Sulfate Inhaler? It's for 200 metered. Thank You
  41. J

    Wiki CPT for Finger reduction

    Hi I need some assist for CPT on Finger reduction. Pt doesn't have a FX or dislocation, Dr thinks its tigger finger. Procedure note below. What do you think should be coded? So stump on this. Thank You "Digital block under aseptic conditions by me using8 cc 1% Lidocaine with no epi and the...
  42. J

    Wiki Diagnosis Code-History of Chronic OM

    Hi I need some help with diagnosis code. I have a new patient who was referred to our office for history of chronic OM but no signs of current OM present. The referral was for possible PE tube placement. How should I code the diagnosis? Thank You in advance. :)
  43. J

    Wiki Dx Help for Genetic Counseling

    Hi I'm reviewing a few edits for Genetic counseling. They are editing for DX is not a primary code, they are using V84.XX only. Should there be another code? Some pt's may have family/personal history of the disease but again not a primary code. Any Help??
  44. J

    Wiki Ultrasound Guidance in ED

    Hi I've been ask to look into CPT codes for ultrasound guidance for IVC size and DVT. I found 93308 Echo but i'm not sure if this is correct. Is this the correct code or is there no ultrasound guidance code for these procedure? Thank You any help will be great!
  45. J

    Wiki Diagnosis Code-plaque in the thoracic aorta

    Thanks!:d
  46. J

    Wiki Diagnosis Code-plaque in the thoracic aorta

    Hi I'm looking for a diagnosis code for "plaque in the thoracic aorta". I looked up Arteriosclerosis but it takes me to Abdominal aorta. I did see 444.1 but that states Emoblism or thrombosis of Aorta and I don't think that's the correct code. Any help please?
  47. J

    Wiki Surgical Path CPT for Heart vessel

    Happy Friday! I'm looking for a Surgical path CPT code for Heart Vessel? I was thinking maybe 88305 but I'm not a 100% sure. My physician code 88302 and 88307 but I don't think either is correct. The report states "consists of three yellow-white pieces of vessel measuring 8 x 5.5 x 2.5 cm in...
  48. J

    Wiki EKG at Each Yearly visit

    HI, Hope your all have a great day..... Question. Is it normal for peds cardiologisit to perfom an EKG at each yearly visit. Patient is not having any problems. But he was diagnosis with Tetralogy. The same day they did an Echo but i believe the EKG was done prior with the Office visit. Any...
  49. J

    Wiki Enteroenterostomy 44130

    That what I was thinking also. Thank you
  50. J

    Wiki Enteroenterostomy 44130

    Hi As anyone billed out 44130 twice with modifier 59 attached to the second line? One of our outside coder billed a procedure this way and we recieved a denial for the 2nd line from the insurance stating max number allowed. I asked the coder to review the report again and she says that two...
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