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    Wiki Pennsylvania Trustmark HOP (PSERS) secondary claims

    Good morning. This question is specific to Pennsylvania providers and Medicare crossover claims. Is anyone finding Medicare primary with crossover to Trustmark (HOP) claims not actually being crossed over to Trustmark? We have quite a backlog of unpaid Trustmark HOP secondary claims that are...
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    Wiki Colonoscopies - surveillance vs. screening

    Hello. To me, coding guidance for surveillance colonoscopies is murky, at best. How are you all coding and billing surveillance colonoscopies for commercial insurances? i.e. repeat colonoscopy for a past finding (polyps) Surveillance colonoscopies are usually done at more frequent intervals...
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    Wiki P1-P6 modifiers

    I am new to Anesthesiology billing and wondered if anyone can provide guidance about this- Medicare (Novitas) and Medicaid (Pennsylvania) do not make any additional reimbursement for the physical status modifiers or for the qualifying circumstances add-on codes, but should we still be putting...
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    Wiki Cholecystectomy with wedge portion of liver

    Our surgeon performed a laparoscopic cholecystectomy and indicated in the note that he removed a wedge of the liver with the gallbladder because there was no definable plane between the gallbladder and liver. The specimen was sent to pathology. Can a wedge resection of the liver be charged...
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    Wiki Laparoscopic partial cecectomy (no anastomosis) coding

    I am on the fence with coding for a laparoscopic partial cecectomy (partial cecum and appendix stump) without anastomosis. Patient is S/P appendectomy, many years ago, and presented with continuous right sided abdominal pain. I have read forums and literature that suggest using CPT code...
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    Wiki Callus shave

    Can codes 11055-11057 be used for billing a shaving of a callus? The procedure note states callus shaved with #10 scalpel. I am thinking that a shave of a callus is included in the E&M code and 11055-11057 should NOT be used since the procedure was a shaving and not paring or cutting. Any...
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    Wiki Lesion excision vs. Skin Tag CPT codes

    I'm second guessing myself on this one. The provider excised a lesion and sent it for pathology. Pathology diagnosis is skin tag. The provider is wanting CPT 11402 (benign lesion excision) to be billed. But, has asked if the 11402 should be changed to 11200, removal of skin tag, based on the...
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    Wiki Cysto with stent removal during ESWL global

    Patient had left ESWL on 12/27/2018. 2 weeks later patient has cysto / left stent ureteral stent removal. Is the stent removal considered part of the ESWL global or can the stent removal be reported separately? Thank you in advance!
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    Wiki Cpt 43760

    Can CPT 43760 be used for a "reinsertion of gastrostomy" at bedside? Thank you in advance.
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    Wiki Preventive visits and Medicare patients

    We have a situation where "preventive health care" and "preventive examinations" are scheduled for Medicare patients. Medicare denies payment, of course, and we are asked to code the visit to an established E&M code, because the Medicare IPPE and Annual Wellness Exam components are not met. I...
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    Wiki Preventive Exams Medicare patients

    We have a situation where "preventive health care" and "preventive examinations" are scheduled for Medicare patients. Medicare denies payment, of course, and we are asked to code the visit to an established E&M code, because the Medicare IPPE and Annual Wellness Exam components are not met. I...
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    Wiki 3 finger fractures same hand

    Hi. I am hoping someone can help me with this one. The patient was diagnosed with 3 fractured fingers of the right hand: the index finger, the long finger, and the ring finger. Closed treatment without manipulation was done for each fracture. 2 splints were applied: one splint for the long...
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    Wiki Open Ventral hernia repair with panniculectomy

    Our patient had a large hernia, approximately the size of a volleyball. Our surgeon elected to perform a partial panniculectomy so the hernia could be closed reasonably without a giant (seroma) cavity. I am having trouble visualizing this. :( There is a CCI edit between the codes 49561 and...
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    Wiki Enertocutaneous fistula

    Looking for any advice, please. Our patient was on the OR table for a laparoscopic sigmoid resection with coloproctostomy. Our surgeon indicated that a laparoscopic "take-down" of an enterocutaneous fistula with oversewing of the small bowel was also done. I am not sure "take-down" is the...
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    Wiki More shoulder woes... 29823

    I am getting really close to understanding this:D I am still a little confused about the reporting for the following scenario. I found that if a provider performs a subacromial decompression, biceps tenotomy, and debridement of the anterior labrum, CPT code 29823 can be reported. But can...
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    Wiki Biceps tenotomy

    Wow. I am finding many differences of how to code for an arthroscopic biceps tenotomy during shoulder arthroscopy. I cannot seem to make sense of it all. Or find a conclusive, agreed upon, coding solution. Does anyone have any recent and up-to-date information? Ortho surgeon performed: 1...
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    Wiki Fracture care 101

    Looking for clarification with regards to global fracture care and cast changes (I'm newer at this--but learning!) :p Global fracture care is 90 days and includes initial casting and/or strapping... Can re-casting [due to a loose cast, mal-fitting cast] be billed separately during the global...
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    Wiki 64405 question

    I am not very familiar with coding / billing for nerve blocks, in this case, an occipital block. The CPT code is 64405. The physician indicated that he used 0.25cc bupivacaine, 0.25cc xylocaine, and 0.5cc of depo medrol 40 mg /cc. Forgive me if I am asking a crazy question-- Are the...
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    Wiki Sacral nerve implantation of neurostimulator

    Would a procedure done on the "contralateral" side of the sacral nerve (transforaminal placement) be considered a bilateral service? Our note states "procedure performed again on the contralateral side" Would the placements be considered bilateral placements? Thanks! Beth
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    Wiki Repair coding help

    Hi. Our physician removed 6 lesions by excision: 3 from the right flank 3 from the left groin All excision coding has been completed, but I am stumped with coding the closures. All repairs are intermediate based on the notes. Right Flank closure total was 13 cm Left Groin closure total...
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    Wiki New to General Surgery coding

    I am starting a new coding adventure soon--I will be diving into general surgery coding. Does anyone have suggestions on specific courses or classes I can take? Is there any specialized training available (on-line)? Or any suggestions on good resources to have at hand? I am nervous, to...
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    Wiki No Review of Systems documented or done HELP!

    Hi. I am looking for suggestions and input for this scenario. I am fairly new to E&M code reviews and am stumped on this. A new patient presents to the office. I have read the documentation through and through and found that no Review of Systems was done. I asked the provider, who responded...
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    Wiki No ROS done

    Hi. I am looking for suggestions and input for this scenario. I am fairly new to E&M code reviews and am stumped on this. A new patient presents to the office. I have read the documentation through and through and found that no Review of Systems was done. I asked the provider, who...
    • bethb
    • Thread
    • Replies: 2
    • Forum: E/M
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    Wiki EGD and Colonoscopy aborted procedure

    I am looking for suggestions for this scenario. I am on the fence as to whether we can bill the endoscopy / colonoscopy procedures with a -53 modifier or if no procedure should be billed at all. Place of service was outpatient hospital. The patient was given preoperative anesthesia to achieve...
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    Wiki Physician Assistant as an assistant surgeon

    Anyone out there have information regarding billing for our physician assistant who is an assistant surgeon to the M.D. for UPMC Health Plan insurances? Here is my dilemma: UPMC Health Plan is not forthcoming with their rules and guidelines for billing such services. I have contacted customer...
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    Wiki 82270 question

    I am receiving a software edit when I billed out a 82270 (FOBT) with a modifier -33 appended to a non-Medicare insurance carrier. I may not be thinking this correctly, but the -33 signifies a USPSTF recommended service. If we bill the screening based on that, wouldn't a modifier -33 be...
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    Wiki Dialysis-Monthly Capitation Payment Medicare

    Hi. I have a billing question regarding the reporting ESRD related services under Monthly Capitation Payments for Medicare. A group practice has 2 physicians. Physician 1 saw the patient on 10/23, 10/26, and 10/28. Physician 2 saw the patient on 10/5. If I am understanding correctly, the...
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    Wiki Medicaid and routine venipuncture

    Our Medicaid (Pennsylvania) is not paying for CPT 36415, as it is not on their fee schedule. 36415 is billed frequently for family practice, and Medicaid will not provide me with any "coding" information or crosswalks, but states there is an "alternative" code that can be billed. I have...
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    Wiki Flu Vaccines

    Hi! I am starting Family Practice billing. I am more accustomed to billing and coding for specialties so I am starting out slow here. I am a little stumped with flu vaccine billing. Medicare references show that Q codes (HCPCS) can be used. Can the CPT codes be billed to and reimbursed by...
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    Wiki Provider reimbursement

    Current question brought to my attention: Group practice employs Drs. A and B Patient sees Dr. A for skin condition. Dr. A provides office visit(s) and suggests ultraviolet light therapy for skin condition. Patient has light therapy on one particular day when Dr. A is not in the office...
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    Wiki Emergency Room Coding

    Hi. I am finding some conflicting information regarding billing for physicians in the place of service emergency room. Can any physician who sees a patient in the ER, regardless of specialty, bill using emergency room CPT codes 99281-99285? For instance, an established patient of Dr. X goes...
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    Wiki EGD with Blakemore tube placement

    I am looking for assistance on finding a CPT code for an EGD with Blakemore Tube placement and gastric bubble inflated. The patient had active gastrointestinal bleeding, and had band ligation, and a large amount of blood was suctioned within the gastric pouch. Thanks, Beth
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    Wiki Place of Service question

    Our general surgeon billed a 62223-62, co-surgeon, with a place of service 22, outpatient hospital. We received a denial from the insurance carrier (Insurance carrier is a commercial plan, not Medicare or Medicare Part C) advising the procedure is not usually "in" the place of service reported...
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    Wiki Medicare Place of Service reporting exceptions

    Good morning! Could anyone out there please help me try and understand Medicare's Place of Service Coding Instructions / exceptions. Our physician saw a patient in the office and our billing was submitted to Medicare status quo--place of service 11, outpatient E/M code was submitted...
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    Wiki Transitional Care Management billing

    Good morning. I was looking for clarification regarding TCM billing (99495 and 99496) in regards to the requirement of contact with the patient within 2 business days post discharge. If no telephone or email contact was made within 2 days of the patient's discharge, BUT, the patient was seen...
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    Wiki Primary insurance and Medicaid secondary

    Good afternoon! Anyone out there from the state of North Carolina? I am having trouble finding clear answers regarding primary insurance and secondary Medicaid billing. I also work on billing for Pennsylvania providers and have a firm grip on Pennsylvania's rules with regard to Medicaid...
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    Wiki PEG question

    Hi. I am thoroughly confused and very new to the world Gastroenterology coding. I am trying to understand this but it's not going so well. Can anyone help explain this to me and help me with the code(s)? "Patient's existing PEG tube percutaneously pulled". The site was sterilized with...
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    Wiki Preventive visit checklist

    Does anyone know of a good preventive visit / exam checklist or template for non-Medicare patients? Thanks, Beth
    • bethb
    • Thread
    • Replies: 4
    • Forum: E/M
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    Wiki Home Health Consolidated Billing

    We bill Medicare Part B / professional services. Our physician is a dermatologist. We billed Medicare Part B for a laboratory service, 88305, global billing, as our physician performs and interprets the test in his office and has the appropriate CLIA certification. Medicare Part B denied...
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    Wiki Fundus examinations

    I have a complicated question and am asking for any thoughts, suggestions, or guidance. Any information is greatly appreciated! The doctor is considering purchasing and performing Fundus examinations in the office. The practice he is with would purchase the equipment, so I am fairly confident...
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    Wiki Fundus examination

    I have a complicated question and am asking for any thoughts, suggestions, or guidance. Any information is greatly appreciated! The doctor is considering purchasing and performing Fundus examinations in the office. The practice he is with would purchase the equipment, so I am fairly confident...
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    Wiki Physician dictation

    Can a non-physician practioner, who is in the exam room with the patient and physician, dictate the visit on behalf of the physician? Thank you in advance for answers, thoughts, suggestions!
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    Wiki Consolidated Billing

    Good morning. I am having trouble understanding Medicare's consolidated billing rules. I do understand that if a patient is in a Skilled Nursing Facility and certain services are rendered and billed to Part B Medicare, those services will deny for SNF consolidated billing. However, we are...
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    Wiki Units of billing for J1030

    Good morning! I am stumped, would anyone be able to help me figure this one out? Our office gave a patient 60 mg of J1030. The first vial, which was a 40 mg single-use vial was adminstered. (1 unit billed) To acheive a 60 mg dose to the patient, a second vial, same as the first vial (40...
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    Wiki Transitional Care Management - when billing

    Hi! I am still trying to thoroughly understand when billing the 99495 / 99496 is appropriate. I have a couple of questions and was wondering if anyone had insight or suggestions on te following? (I have read, and re-read the FAQs on CMS' website, AAFP FAQs, and the CPT code book and I am...
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    Wiki Home Health Certification

    Our patient had multiple major surgeries over a months' time as part of cancer treatment. The patient was ordered home health care after the surgeries and our physician ordered and signed the home health certification, so we billed G0180 and Medicare paid. However, the patient experienced a...
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    Wiki Medicare Advantage Plans vs CMS

    I am located in Pennsylvania and we are having some major issues with a Medicare Advantage Plan and their methodology for muliple surgery reduction amounts. This MA is paying the primary procedure at 100%; second procedure at 50%; and third / subsequent procedure(s) at 25 % of their allowable...
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    Wiki Medicare Advantage Plan vs CMS

    I am located in Pennsylvania and we are having some major issues with a Medicare Advantage Plan and their methodology for muliple surgery reduction amounts. This MA is paying the primary procedure at 100%; second procedure at 50%; and third / subsequent procedure(s) at 25 % of their allowable...
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    Wiki Billing Question Help!

    Our provider, is asking if there is a code to bill for the following service he performed: Dr. met with the patient's family (patient was not present) to initiate Hospice care and end-of-life planning for the patient. He spoke with the family, and completed paperwork, and made phone calls. (...
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    Wiki CPT 88331 question - Our doc is wanting

    Good afternoon. Our doc is wanting to charge for CPT 88331. I have done reading and research but I cannot seem to either find the answer or truly understand the logistics of the code 88331. Doc states separate specimens and has the codes as such: 88331, diagnosis 173.31 88331-59, diagnosis...
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