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  1. K

    Wiki Coding Lesion Removal

    Is there a decision tree for Lesion Removal ? My doctor does Lesion Removals. He mainly uses CPT # 67810 or # 67840. When the biopsy is more than superficial my note says to use # 67810 . When the entire lesion is removed use #67840. This code involves lid margin, tarsus and palpebral...
  2. K

    Wiki Diagnosis

    I have an older Retina physician who still does handwritten notes. Sometimes she doesn't always give me diagnosis codes but instead gives me history codes. She may also give me codes that she doesn't address in the note. My question to you is can I give diagnosis codes from diagnostic tests (...
  3. K

    Wiki Billing E & M coding for Level 4 visits

    I am having a hard time understanding the 2021 E & M coding for level 4 office visits. My physician may see a patient who has 5 different issues that she is handling. That would at least qualify her for a Level 4. The issue I am having is satisfying The Amount of Complexity and Data to be...
  4. K

    Wiki Super Glued Eye Shut -Procedure Code to Re-open the Eye

    Our physician saw a small child in the ED and had to put the child under Anesthesia to remove the stuck together eyelashes so the child could open her eye again. Is there a procedure code for this ? Would an Unspecified code be used for this ? What would be similar in RVU value ?My physician...
  5. K

    Wiki DSO or DWEK- Ophthalmology Surgery

    Our physician did a DSO or DWEK. Does anyone know what the CPT code would be for this ? Thank-you Kathy Albert
  6. K

    Wiki OCT vs Fundus Billing

    I have a question regarding OCT and Fundus exams. I was told to bill for the Fundus exam and not the OCT due to NCCI edits. I noticed though that the OCT has higher RVU's for the physician than the Fundus. I work for a hospital based clinic. Which one would you bill out for ? Thank-you Kathy...
  7. K

    Wiki Best Specialty Coding Book for Opthalmology

    Who makes the best Opthalmology Specialty Book with the best pictures, explanations, diagnosis codes, RVU's and NCCI Edits. Kathy
  8. K

    Wiki Eye Injections

    I have another question. Our Retina doctors do injections in the eyes. It may be every few months, sooner, later,etc. They always do a complete exam and usually an OCT. We bill for the injection and OCT only, as that is what is on the schedule as to why they are there. It seems that we should be...
  9. K

    Wiki Comprehensive Eye Exam

    If the Physician performs all of the Elements of the eye exam , but doesn't put in anything about Neurologic or Psychiatric,does that void the Comprehensive Eye Exam ? Would an E & M code need to be billed out then ? I am still confused over this and don't know if my Physician needs to know...
  10. K

    Wiki Yearly Comprehensive Eye Exam for Diabetic Patient

    I am having issues with the Comprehensive eye exam codes. I have Diabetic patient's who are coming in for their yearly exam. The physician performs a complete exam. He will put at the end; "no diabetic retinopathy in both eyes". I know it would be considered comprehensive if an OCT, or other...
  11. K

    Wiki Really Stumped on How To Code This

    I am really stumped on how to code this. I cant seem to find the proper CPT code. I would really appreciated an experienced coders help on this. Here is the OP report. Preoperative Diagnosis: Presumed seminal vesicle mass. Postoperative: Likely rectal tumor. Procedure: Transrectal sonography...
  12. K

    Wiki Billing for Mirena Removal with Re-Insertion

    I have always billed the Mirena removal with re-insertion as # # 58301-dx V25.12 and # 58300-dx V25.11 and also the Mirena as # j7302. I have heard others code it as # 11981-insertion, # 11982-removal or if both done use # 11983-dx V25.43. What is the correct codes to use? What is the...
  13. K

    Wiki Colonoscopy-billing ov prior to procedure

    I know that this topic has been addressed many times. I know that an office visit prior to a screening on an asymptomatic patient is non-billable. The billing company I work for is trying to tell me that it is billable. They say that those rules apply only to Medicare patients? The diagnosis the...
  14. K

    Wiki Billing for 2nd E&M visit prior to 2nd Carpal Tunnel Surgery

    Insurance company is denying paying for the second E&M visit prior to the patient having the other side done. I used a 24 modifier as it was in the post-operative period. Are we allowed to bill for this E&M visit since it was on:confused: the other side?
  15. K

    Wiki Intra operative frozen section

    When a physician does a revision to a total knee or hip and does an intra-operative frozen section-can we bill for that or is it considered part of the surgery? Thanks Kathy
  16. K

    Wiki Consultation and admission to observation

    Our physician was called down to the ER by the ER physician.He did a consult and admitted the patient to observation.Can the consult and the admission to observation both be billed out or just the observation admit? Thanks Kathy
    • kathy a
    • Thread
    • Replies: 2
    • Forum: E/M
  17. K

    Wiki Colonoscopies-surveillance

    A patient is coming to the office to set up for their surveillance colonoscopy. He/she was seen over 5 years ago and had a colonoscopy then and was diagnosed with diverticulosis,polyp,etc. Can we bill the new patient office visit again. Diagnosis codes are V12.79 and V76.51? Thank-you Kathy
  18. K

    Wiki Re-pap

    Patients first pap was abnormal so she is coming in for a re-pap. How do you bill for that and what diagnosis codes are used? Thank-you Kathy Albert
  19. K

    Wiki Level of Code for Medication Refills

    I bill for a workers comp group.Patient is coming in for medication refills.The physician has documented a detailed to comp exam,a detailed to comp ROS.IN medical decision making he gets a low complexity for that as patient is doing fine but needs refills. I saw a webinar that said if patient is...
    • kathy a
    • Thread
    • Replies: 2
    • Forum: E/M
  20. K

    Wiki Admission with Surgery

    If patient was seen in the office and it was determined that they were going to have a total hip, and the physician admitted the patient the next day and did the surgery that day can I bill for the admission and the surgery?
  21. K

    Wiki Shoulder arthroscopy's

    Patient had a Mumford procedure-# 29824 with subacromial decompression # 29826. He also had an intra articular debridement of a flap tear? Not sure on this one?Any help would be greatly appreciated. Kathy:confused:
  22. K

    Wiki Yearly Gyne Exams

    Our physician states in his notes that -Rectal exam deferred at this time. Stool sample for occult blood test not indicated. Should I be billing for the occult blood test? When he states in his notes Hemmocult done I do bill for the 82270. Also can we bill for a rectal exam if performed, or is...
  23. K

    Wiki Abdominal fat pad biopsy

    Our physician did an aspiration of the abdominal fat pad for biosy in his office.This was done to see if the patient might have Amyloidosis. I am having trouble finding a code to fit this.Any help would be greatly appreciated! Thanks! Kathy :confused:
  24. K

    Wiki Billing patient ov with a fracture

    Can anyone please answer this for me? If a patient is coming from the OR, or as a consult or referral ,and they are new or established to the office, and have a fracture, can we bill an office visit? We do a complete HPI and a Detailed ROS.Also if patient has medicaid and they are new or...
  25. K

    Wiki Billing for Guidewires?

    Her is an op report and would appreciate some feed back as to how you would code this. With patient under general anesthesia and the dorsal lithotomy position the peroneal and genital area was prepped and draped in the usual sterile fashion.Patient was given 120mg gentamycin IV prior to...
  26. K

    Wiki Billing for double J stents for both sides?

    I had a patient who had cysto with lithotripsy done on both the right and the left. He also had 2 double j indwelling stents placed. His insurance is denying this. I used : # 52353-RT,22 # 52353-LT # 52332-50 # 74480-26 dx- 592.1 Our physician had difficulty on the right, so I added a 22...
  27. K

    Wiki Billing For 2 CMC dislocations/Fractures

    When billing for 2 dislocation/fractures for CMC joints do you use a 59 or 51 modifier on the second one.Or should I use the #26676 with 2 units. Thanks Kathy
  28. K

    Wiki Billing for a Vaginal Culture

    Our physician does different cultures of the vagina. Am I allowed to bill for these and if so what code? Or is this generally something the lab charges for? Thanks Kathy
  29. K

    Wiki Care in the Post-partum Period

    I know that there isnt any global on a delivery. Some people say it is customary to allow 6 weeks. What if patient after having a C-section had an infection in their wound and has followed up numerous times for re-packing of wound and wound check? Should I be billing for these visits? Thanks...
  30. K

    Wiki BIlling OV after a Colonoscopy or EGD

    I would like to know if any of you bill for an office visit after a Colonoscopy or EGD. Even though it is normal, or doctor found a polyp and tells the patient to follow up in one or five years, it still seems like it to me that the patient would be eligible for a post op visit. The follow up...
  31. K

    Wiki Pessary Cleaning - When a patient comes

    When a patient comes in every 3 months to have their pessary taken out, cleaned and re-inserted do we charge an E&M-usually a # 99213 visit along with #57160.Or is #57160 to be charged for the initial pessary fitting or when a new pessary is put in? I know if it is a new one we charge the A4562...
  32. K

    Wiki Fetal Demise-Our physician did

    Our physician did a treatment for an incomplete abortion due to fetal demise in the first tri-mester. I believe the code for this is # 59820-dx- 632. I went on line to see what the difference between #59812 and # 59820 was. #59812 is for an incomplete abortion-patient was aborting fetus-not all...
  33. K

    Wiki Removal of gastrostomy tube

    Our physician did a removal of a gastrostomy tube in the OR. Reading the CPT code descriptor and looking on-line ,CPT code # 43870 is an open surgical procedure requiring stitches. It also states, that if stitches were not used to use # 49999 the unlisted code? Some people have used # 43247...
  34. K

    Wiki Coding for an attempted repair of a slap lesion

    My physician did a diagnostic arthroscopy of his patients shoulder . Contrary to what the MRI said this patient had a slap lesion. He attemted to do the repair, however due to the inability to get a safe anchor point for her and her labrum tear pattern appeared beyond his ability to repair he...
  35. K

    Wiki Exp Problem Focused Exam

    I have a question regarding E & M coding. If a doctor doesnt do a ROS- but in the HPI talks about why patient is here and the problem applies to one system-ie patient here for arm pain.(this would be musculoskeletal) can this count as pertinent to problem-1 system?-which would fall under Exp...
    • kathy a
    • Thread
    • Replies: 2
    • Forum: E/M
  36. K

    Wiki Fracture Coding

    I have a few fracture questions and wonder if someone could help with some answers. If a patient comes to our office as a new patient but was seen in the ER for a fracture can we charge for the new patient office visit and the fracture care? Example-Would we use a dx of arm pain for the office...
  37. K

    Wiki Colonoscopies - The Cutting Edge had a good

    The Cutting Edge had a good article in its March issue regarding colonoscopies. It now states that colonoscopies are divided into 3 categories-Diagnostic, Preventative, and Surveillance. Which is great and makes sense.If the patient is having problems-it is Diagnostic. If patient is over 50 and...
  38. K

    Wiki Stll Learning OB/GYN-Billable Prcedures done in the Office

    What procedures are billable in the OB/GYN office? I know that we can bill for yearly visits, paps, wet mounts, and hemmocults as well as EMB's and IUD insertion and removals. And for the OB's their visits. What else is billable. Can we bill for STD testing, Cultures?
  39. K

    Wiki So Many Procedures-Not Sure

    Our Urology group did a Cystoscopy with clot evacuation, Bilateral Retrograde with Pyleograms, a Left Uteroscopy, a Right ureteral stent placement and a TURBT.These are the codes I came up with: 52355-RT 52001-59-LT 52332-51 dx- 189.1 50394-51 74425-26 dx- 599.71, and 189.1 Can someone please...
  40. K

    Wiki Closed Fracture Care and Open Fracture Care

    Our physician saw a patient in the ER for a bi-malleollar fracture of the ankle. He casted her while in the ER and did take X-rays. He decided to admit the patient and to do an ORIF of the ankle the next day. Would I be able to charge the Admission-# 99222-25 with #27810-RT, and the Xray...
  41. K

    Wiki Periprosthetic Fracture Femur-Vancoover B

    Having problems coding a surgery in which the patient had an ORIF of her left femur-she had a total hip replacement a month previous and had a prosthesis put in, so she no longer has her trochanters.Her diagnosis is peri-prosthetic fracture involving her prosthesis. Doctor replaced her...
  42. K

    Wiki Biomet Stage 1

    Has anyone of you coded the Biomet Stage 1 cement molds used in a femur/ tibia ? Our patient has colon cancer and her implant was removed, and the doctor used antibiotic impregnated spacers instead of putting another implant. This was due to the fact the patient is waiting to under go...
  43. K

    Wiki New to ob/gyn coding

    I am still learning OB/Gyn coding and have a few questions regarding deliveries. If a person is induced, we dont charge for the induction, unless it failed and patient goes home? Then you would code using what code? When would you charge for a cervical dialator? Do you ever bill for the...
  44. K

    Wiki 3 breaks

    Post Op Dx-Left 5th digit proximal phalanx involving 3 fragments. Procedure-open reduction and internal fixation left proximal phalanx. My question is: I believe the procedure code is #26735-F 4.My question is physician states that he did all three fragments on F-4. Would the code still be the...
  45. K

    Wiki Colonoscopy Coding

    I really seem to be struggling with patients that come in for screening colonoscopys. The patient comes in for a screening, and is a new patient referred by their family physician. According to Medicare guidelines we cannot bill for that pre-op-even though our physician has never seen that...
  46. K

    Wiki Learning As I Go-no help

    Help! New to urology coding. Doctor states patient had a Nephrouteroscopy. Would this be # 52351, # 74485 and # 74420. Doctor mentions he did a retro-grade pyleogram in his notes:confused:. He doesnt talk of using any dyes but does use guidewires. Im confused?? Thanks...Kathy Albert,CPC
  47. K

    Wiki Bladder Stones and BPH

    Help! New to urology coding. Procedure performed was a PVP laser Prostatectomy and Cystolitholapaxy. The codes I thought this would be is 52648 and 52318. Also on stones-if the measurement of the stone was 2.1 x 1.7 cm-do you take the larger size for measurement-which would be 2.1 cm...
  48. K

    Wiki Application of a new cast during a global period

    I have a patient who returned for a wrist fracture. She had cut off her cast. Her arm was still fractured and the doctor put on a new fiberglass cast. Can I bill a 29085-LT with a diagnosis code of V76.51-patient non compliance to medical care and a Q4010 for the supplies. I read somewhere that...
  49. K

    Wiki Delivery and a consult

    Our physician did a Vbac for a patient who was not hers.Patient was brought to the hospital by ambulance. Our physician was called to the ER by the Er doc and ended up delivering the baby by VBAC.Along with the delivery, can I bill a consultation or ER visit?
  50. K

    Wiki Coding for replacement casts

    I RECIEVED DENIALS FOR TWO OF OUR REPLACEMENT CASTS. IF THE PATIENT DAMAGED THEIR CAST DUE TO NEGLECT OR PUNCHING HOLES IN THE WALL, CAN WE NOT BILL FOR THE REPLACEMENT. I USED CODES FROM THE 29065-MODIFIER 58 AND Q4006.CAN WE NOT BILL FOR THESE?tHANKS!:confused:
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