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    Wiki Weight loss leading up to bariatric surgery

    Patient has 37.4 BMI and presents for bariatric surgery. Sleeve gastrectomy approved by Medicare replacement plan. Patient goes through the nutrition counseling, psych eval, etc. and proceeds to drop BMI to 33.5 just before surgery. BMI is now under the required 35. I can't find where it clearly...
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    Wiki 78,80 modifier usage

    Patient had surgery by Dr. X. Dr. X was in a practice with several general surgeons and left the practice during global period. Dr. Y was consulted on a Dr. X patient with post op pain, CT showed free air and intussusception. Dr. Y took patient to OR and requested assistance with Dr. Z. Dr. Y...
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    Wiki UTS guided breast bx

    I'm pretty sure I know the answer - just looking for confirmation. 19083 is percutaneous breast bx with UTS guidance. As UTS guidance is in the definition the reimbursement for UTS technical and professional components are included, correct? In other words, it would be wrong to bill 19083 as...
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    Wiki 92622 new code

    Has anyone billed this new code for BAHA? Are payers paying (commercial and CMS) you? Does anyone have guidance on documentation requirements - specifically regarding time documentation?
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    Wiki Q6 locum tenens in Florida

    Does anyone know which payers (other than Medicare) accept Q6 modifier and which do not in Florida? I'm researching myself now but any help is greatly appreciated. Thanks, Hunter Smith,CPC
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    Wiki New '23 hernia code documentation

    I have some guidance on how to select codes from the new hernia codes from various sources but I'm not able to find anything from CMS. Does anyone have guidance from CMS on how to document the size of the defect? Specifically, in the AMA/CPT book it states "the hernia defect size should be...
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    Wiki General Surgeon "Fellow"

    Surgeon A is primary surgeon, performs left mastectomy. Surgeon B is a Fellow that is acting as an assistant surgeon and performs right mastectomy at same time. Surgeon A is in OR entire time Surgeon B is, Surgeon A dictates note for himself and in the note refers to Surgeon B as the assistant...
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    Wiki Wire localization separately reportable?

    Any assistance on resolving a debate is greatly appreciated. Surgeon is placing wire localization in the OR with ultrasound or stereotactic guidance prior to beginning any other procedure (biopsy, lumpectomy, mastectomy). After completing the wire localization the surgeon then begins and...
  9. H

    Wiki Reverse shoulder CPT

    23472 is the code for a total shoulder arthroplasty, whether traditional or reverse, correct?
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    Wiki 99211 for Home Sleep study

    So we have a debate if we can/can't bill a 99211 for the visit when a patient comes in to get their home sleep study equipment. The nurse note: All instructions clearly communicated and demonstrated to patient for home sleep study using the ARES. Placing the ARES on after thoroughly washing...
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    Wiki E&M based on time, what can be included?

    Documentation: Greater than 60 minutes was spent on today's visit including review of multiple outside records, appropriate physical examination, review of today's testing with the patient and her husband, discussion of options for further evaluation, ordering of testing and documentation of...
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    Wiki Decision for surgery mod new hernia codes

    With the new anterior abdominal hernia codes that have 0 day global period are we to use mod 25 for the decision for surgery E&M or mod 57? Thanks for any assistance, Hunter Smith, CPC
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    Wiki Measuring defect on new hernia codes

    I understand the guidelines on the new hernia codes are to measure the defect prior to surgery, prior to incision. However, can anyone offer guidance if the surgeon identifies the size of the defect after inserting the trocars/camera and defining the defect size from "inside" the patient vs...
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    Wiki Excision epidermal inclusion cyst

    Happy New Year! Need some help with an excision code debate: A 2.5 skin incision was made. The incision extended all the way down to the subcutaneous tissue. The platysma muscle was identified and divided. Deep to the platysma muscle there was an epidermal like mass that appeared to be well...
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    Wiki Coding assist please

    Please advise how you would code this to resolve two conflicting opinions: After supine and general anesthesia through laryngectomy stoma... Next, using the anterior commissure laryngoscope the oral cavity, oropharynx into the neopharynx is well visualized. No evidence of recurrent disease...
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    Wiki Parastomal hernia

    Debate on the correct coding of the following operative report. Assistance is greatly appreciated. "The parastomal hernia was located somewhat slightly superior and lateral to the conduit. We make an incision after anesthetizing the area about the 9 o'clock position outside of the ostomy bag...
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    Wiki parastomal hernia of ileal conduit

    Debate on the correct coding of the following operative report. Assistance is greatly appreciated. "The parastomal hernia was located somewhat slightly superior and lateral to the conduit. We make an incision after anesthetizing the area about the 9 o'clock position outside of the ostomy bag...
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    Wiki 47562 or 47563

    Ongoing debate about if cholangiogram is documented and can be billed. From the Op note: "At this point, ICG interrogation was then performed and the ICG cholangiogram demonstrating the gallbladder, cystic duct, and the common duct features. Next, dissection was then performed using the...
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    Wiki Infusion with hydration

    Patient received infusion of Remicade. Remicade is administered with NS. Patient has Medicare Advantage plan. Do I bill: a) 96413/96415 based on time of infusion for the Remicade, or b) 96360/96361 based on time of infusion of NS, or c) both 96413/96415 and 96360/96361 based on time of...
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    Wiki Drain seroma post-op billable?

    Current debate between coders and surgeons: I&D or drain seroma (related to surgery) is separately billable and not "included" in the global period. Yes/No? Please provide references for use in the debate. Thanks so much, Hunter Smith, CPC
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    Wiki Excision coding advice

    Having a debate on correct coding of the below. Any help is greatly appreciated. Procedure: excision with intermediate layered closure Preop diagnosis: mid back and low back lesion Postop diagnosis: same Location: mid back, low back Size of lesion: 1x1, 2x2cm mm Size of defect: 3, 1cm mm...
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    Wiki Spinal op note help

    We are currently trying to confirm correct coding - I have run this through the Codify Scrubber already - but looking to confirm nothing missed as well as modifiers that scrubber is not clear on. Stab incision was made over the left PSIS and a stealth frame was inserted. Intraoperative CT scan...
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    Wiki Unlisted surgery with other surgery codes

    So, we have an unlisted code for a surgical procedure and other surgical procedures were done. The comparative CPT has a higher RVU than the other codes that have a CPT. Based on this, should the unlisted code be billed first and subsequent codes have the -51. Or, is there a rule that the...
  24. H

    Wiki Wound Vac

    Received a denial for 97605 from Humana. The denial states "submitted medical records does not include documentation that supports negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound...
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    Wiki 99424 require 30 minutes?

    Hi, I know codes with the time listed in the definition require 51% of the time to be met to enable the code to be billed. Is anyone aware this standard does not apply to 99424, the new code for principal care management? Thanks for any assistance and links you can provide and Happy New Year...
  26. H

    Wiki Screening or diagnostic colonoscopy?

    So a friend had a colonoscopy, first done in 2012, 2 polyps found and removed. Second colonoscopy done 2015 1 polyp found and removed. Third colonoscopy done 6/2021 1 polyp found and removed. Never had any symptoms, melena, etc. Colonoscopy was done at ASC partly owned by the GI that performed...
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    Wiki Hyperbaric Supervision (99183)?

    There were LCD's to follow but now the LCD's are retired and I'm unable to find any guidance on what is required to get these paid. Can anyone give me guidance on what is required to get these claims paid? CMS is denying every claim for not meeting "medical necessity" for DX codes that...
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    Wiki Add 99211 to Prolia only visit

    Currently I'm billing a 96372 along with the Prolia J Code. The plan of care had already been determined, Prolia shots, etc. Office manager feels there should be more profitability in the "visit" than the 96372 and the thin margin on the Prolia. Office manager thinks nursing should start...
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    Wiki LAP APPY THEN RETURN TO OR

    Patient presented for emergency lap appendectomy and surgery was completed with no complications. However, post-op patient started declining, hypotensvie and tachycardic. MRI of abdomen revealed massive hemoperitoneum. Patient was informed and then disclosed that he regrettably had not told the...
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    Wiki GY on S codes

    I am billing S0164 and S9379 to Medicare Texas (Novitas). Patient previously had BCBS primary and they paid $57+/day combined for the two codes. Patient has daily home infusions so $57+ = over $1,700/month in reimbursement from BCBS. Now that Medicare is primary they are rejecting on receipt...
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    Wiki Covid and telemedicine rules

    Can anyone tell me with the pandemic relaxed rules on telemedicine if CMS eliminated the requirement to do a physical exam on a new patient? Any links to source information is greatly appreciated. Thanks, Hunter Smith, CPC
  32. H

    Wiki Telemedicine and physical exam

    Can anyone tell me with the pandemic relaxed rules on telemedicine if CMS eliminated the requirement to do a physical exam on a new patient? Any links to source information is greatly appreciated. Thanks, Hunter Smith, CPC
  33. H

    Wiki CMS Telemedicine for new patient

    Can anyone tell me with the pandemic relaxed rules on telemedicine if CMS eliminated the requirement to do a physical exam on a new patient? Any links to source information is greatly appreciated. Thanks, Hunter Smith, CPC
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    Wiki Humana Medicare and AWV

    I'm being told by a CPC at Humana that Humana requires the Humana Medicare Annual Wellness/Subsequent Annual Wellness to be performed by a clinician (MD/DO/PA/NP). I presented 2 links from CMS that clearly/explicity state it can be done by: "Medical professional (including a health educator...
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    Wiki How to bill for providing and administering allergy immunotherapy

    We are getting premixed vials of allergen immunotherapy and the vendor bills us for the premixed vials. We pay the vendor and then we administer the immunotherapy. As the vials are sent premixed, the provider is not doing any aliquot/preparation of the immunotherapy, only in the very rare case...
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    Wiki 59 or no 59

    Please help me settle a difference of opinion. Which is the correct way to bill an office visit and I&D (10060)? A) 99213- 25 and 10060 B) 99213-25 and 10060-59 C) 99213 and 10060-59 Thanks, Hunter Smith, CPC
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    Wiki E/M Distribution for Urgent Care

    CMS has what they expect, what OIG expects for E&M code distribution in an office/outpatient primary care setting. Does anyone know where I could find the same data specifically for Urgent Care facilities? Someone is telling me "we should have 85% of our new patient visits be 99204" and that...
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    Wiki Using Locum tenens as rendering

    A locum tenens is filling in for a physician out for surgery. The facility also does urine drug screens for multiple locations of the same company and the rendering (box 24J) has always been listed as the physician there in the location where he sees patients in the building with the urine drug...
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    Wiki POS 11 or 81

    Any assistance to help with a debate is greatly appreciated. Some of the questions may seem ridiculous, but I'm trying to resolve a debate. Scenario: 20+ locations of a primary/urgent care business crossing state lines. High complexity CLIA certificate at a location in state "X" where high...
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    Wiki Under coding on Urine Drug screens acceptable?

    Suppose G0480 is the only code from G0480-G0483 approved for reimbursement/on the fee schedule for a payer that makes up a considerable part of your payer mix. Suppose the provider is going to prescribe opiates for chronic pain and manage this pain long term. Suppose a new patient comes in to...
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    Wiki Infusion + shots

    We have pt that comes in regularly for Xolair injections and we bill and are paid billing it as follows: 96372-RT 96372-LT 96372-RT/59 This pt recently came in for Reclast infusion on same date as Xolair injections. We billed as follows: J3489 - paid by BCBS 96365 - paid by BCBS 96372-RT -...
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    Wiki Correct use of modifier XE

    CMS introduced X (E, U, S, P) 1/1/15. I am being told it is correct to use modifier XE in place of 59 in the following situations: 1) Established out patient is seen for a problem visit and has an EKG done. Bill as 9921"x" and 93000-XE (NOTE, the EKG was done during the same encounter, patient...
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    Wiki 95803 Actigraphy reimbursement

    I have a billing client that is a sleep specialist that has purchased several actigraphy devices to be worn by patients. The CPT code is 95803. I have not been successful in getting any payer, commercial or CMS, to pay for the testing - even though the testing is done on dates of service other...
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    Wiki Quantitative Drug screen codes G0481-G0483

    I have a client that is billing South Carolina Medicaid for G0481, G0482, and G0483 and SC Medicaid only pays for G0480. Can anyone give me any guidance on why Medicaid only pays G0480 and not G0481-G0483? Thanks, Hunter Smith, CPC
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    Wiki Skilled NF frequency

    I bill for a geriatrician that has "heard" of a physician that performs the initial E&M on a newly admitted patient and then has PA's/NP's that are employed by the physician (not the SNF) that go to the SNF every single day to see patients. 1) it has been our understanding a "billing provider"...
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    Wiki Venous ligation code help

    Pt was tender to touch on scalp over "mass" so my surgeon took to the OR to excise the "mass." Following is op note I need help coding. Once she was positioned, the surgical site on the posterior right head measured approximately 2 cm x 2 cm palpated. The surgical site was prepped and draped in...
  47. H

    Wiki Help with liver procedure

    Any suggestions on how to code this is greatly appreciated! Summary - Diagnostic laparoscopy, right lobe of liver biopsy of a tumor (laparoscopic), converted to open laparotomy with partial hepatectomy (segment 6). After informed consent.....Following placement of all trocars, the laparoscope...
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    Wiki Removal of two catheters, insert one

    Background: Patient has ESRD with malfunctioning peritoneal dialysis catheter. Presented to ED with fluid overload and my surgeon placed a non-tunneled central venous catheter (36556) Vas-Cath to allow emergent dialysis. Four days later.......the plan is to: 1) remove malfunctioning peritoneal...
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    Wiki replace removed gastrostomy tube

    Please help me code this one!! Thanks for any assistance. Patient had gastrostomy tube placed, increased leakage was noticed, presented to ER and patient admitted to manipulating the gastrostomy tube. Was taken to the ER and below is the Op note: ....Exploration of the former gastrostomy site...
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    Wiki Wound clinic billable during global period?

    My doc did an open cholecystectomy on a diabetic and therefore slow/poor healer. He then saw the patient in the wound clinic as one of the general surgeons rotating through the wound clinic. The wound clinic visit was within the global period of the cholecystectomy. Is the wound clinic billable...
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