General Surgery Coding Alert

CPT® Update:
Check out These Vascular Surgery 2022 Code Changes
Aorta coarctation repair marks additions for next year. With new options for reporting se... Read more
E/M Documentation:
4 Q&As; Clear Up MDM Confusion
See how to tally number and complexity of problems. With nearly a year of reporting E/M ... Read more
Vaccine Mandates:
Consider HIPAA Impact on COVID-19 Measures
Know what action you can take. If your surgery practice is considering a COVID-19 vacci... Read more
Reader Questions:
Engage Physician for Most Specific Dx
Question: I'm coding an op report for an EGD to treat esophageal varices (I85.00). But the... Read more
Reader Questions:
Scrutinize Time for Prolonged Service
Question: Our surgeon performed an extensive office evaluation and management (E/M) servic... Read more
Reader Questions:
Check Limb Length for Roux-en-Y
Question: The surgeon performed a laparoscopic gastric restrictive surgery for obesity by ... Read more
Reader Questions:
Practice HIPAA Compliant Faxing
Question: What are the HIPAA rules regarding using a fax to transmit lab test results? Ca... Read more
You Be the Coder:
Adjacent Tissue Transfer Stands Alone
Question: Our surgeon performed an excision of a 0.5 x 0.6 cm basal cell carcinoma on the ... Read more
CPT® 2022:
Check Out New Surgery T-Codes and More Before Jan. 1
From transnasal EGD to POEM, you've got a lot to learn. Uncharacteristically, most of the... Read more
Clarify 99211 for CPT® 2022
Note chronic care management updates, too. After nearly a year living with code revision... Read more
Expect CMS to Sunset MIPS by 2027
And look for MVP reporting delay. With the six-year anniversary of the Quality Payment Pr... Read more
Reader Questions:
Up the Ante on Bilateral Documentation
Question: Our provider performed a bilateral ultrasound (US)-guided fine needle aspiration... Read more
Reader Questions:
Pinpoint COVID Vaccine Adverse Reaction Codes
Question: How do we code an adverse reaction to a COVID-19 vaccine that was noted by a phy... Read more
Reader Questions:
Use CMS-838 For Return Payment
Question: How can we be sure we're refunding the correct amount when a claims processing e... Read more
You Be the Coder:
Avoid Patient Payment for Screening Colonoscopy
Question: Our surgeon performed a screening colonoscopy for a 65-year old Medicare patient... Read more
CPT® 2022:
Change Reporting Habits for Principal Care Management
See how CPT® and CMS clear the way. Changes to reporting E/M services didn't stop in 202... Read more
ICD-10-CM Update:
Incorporate New Dx Coding by Oct. 1
COVID-19 and GI changes top the list. Don't miss out on diagnosis coding updates — your... Read more
Get ‘Surprise Billing’ Disclosures in Place Now
You can still bill out-of-network balance — with permission. Known as the No Surprises ... Read more
Reader Questions:
Focus This Ovarian ‘Borderline’ Tumor Dx
Question: The pathology report for a left oophorectomy identifies “serous tumor of low ... Read more
Reader Questions:
Use Caution with Complication Billing
Question: Our surgeon performed a flexible sigmoidoscopy with the intention of performing... Read more
Reader Questions:
See If HIPAA Constrains Employers
Question: Can employers request employee lab test results for COVID-19 testing or does HIP... Read more
You Be the Coder:
Distinguish Venipuncture Codes
Question: What is the difference between venipuncture codes 36400-36410, 36420-36425, and ... Read more
Vascular Surgery:
Master Your Swan-Ganz Coding with These 3 Tips
See when to bundle CVA. Many clinical scenarios call on vascular surgeons to use a diagno... Read more
Medicare Physician Fee Schedule 2022:
Proposed Rule Offers Telehealth Changes for Next Year
Look out for critical care bundles with global surgery. With no end in sight for the COVI... Read more
Silence HIPAA Misconceptions About PHI Disclosure
Give patients requested records. Keeping protected health information (PHI) private is g... Read more
You Be the Coder:
Distinguish Modifiers 66 and 62
Question: Our general surgeon worked as part of a surgical team for a liver transplant in ... Read more
Reader Questions:
Time is On Your Side
Question: I have a procedure note indicating that the provider performed an outpatient eva... Read more
Reader Questions:
Go for Modifier 58 Without Complication
Question: Our surgeon excised a 1.2 cm melanoma, but returned the patient to surgery three... Read more
Reader Questions:
Update PHE Deadline
Question: What is the current status of the PHE for COVID-19, and when can we expect it to... Read more
Reader Questions:
Dictate Dx from Pathology Report
Question: We're coding an op report for an excised polyp from the rectosigmoid junction th... Read more
Integumentary Case:
Distinguish Skin Biopsy Vs. Excision Based on Intent
Choose procedure code with pathology report in hand. Integumentary procedures hold lots o... Read more
Evaluation and Management:
Turn to Virtual Check-In for Telephone-Only E/M
Distinguish G-codes from 99441-99443. While you may have focused on telehealth services d... Read more
Query Surgeons with Confidence for Clean Claims
Look to CMS for guidance. When you need to clarify an op report with your surgeon, you sh... Read more
You Be the Coder:
Avoid Enteroscopy Codes for Duodenum ‘Peek’
Question: We have an op report for a procedure described as a diagnostic EGD for gastroeso... Read more
Reader Questions:
Recognize Different MDM Tables
Question: Can we use examples from the Table of Risk currently provided by the Centers for... Read more
Reader Questions:
Halt Modifier 63 With Infant Cutdown
Question: Our surgeon attempted percutaneous venipuncture for a 2 months old infant weighi... Read more
Endoscopic Surgery:
Dominate US Guided GI Procedure Coding With These 4 Steps
Don't unbundle separate steps. Whether down the hatch or up the other end, CPT® provides... Read more
E/M 2021:
Grab Our Experts’ Take on Revised 99202-99215 Implementation
See how MDM focus has changed everything. With completely different descriptors and guide... Read more
Vet Your BA’s HIPAA Harmony Before Hiring
Their non-compliance may be your liability. As a surgeon, you're a covered entity (CE) ... Read more
You Be the Coder:
Look for Colonoscopy Medical Necessity
Question: Our surgeon performed a colonoscopy and internal hemorrhoidectomy by band ligati... Read more
Reader Questions:
Follow Excludes Note to C7A.0
Question: Our surgeon performed an ileum biopsy, and the pathology report states a diagnos... Read more
Reader Questions:
Get the Lowdown on POS Codes
Question: Could you please clarify what the POS codes are that surgeons might use and how ... Read more
Reader Questions:
Abide by State Regulations for Minors
Question: We have a 17-year-old patient who has requested that we not discuss her care wit... Read more
Reader Questions:
Look for Separate ECMO Initiation
Question: Are codes 33948 and 33949 the only codes available for ECMO services? Louisiana... Read more
Abdominal Surgery:
3 Tips Demonstrate Key Terms You Need to Know for Splenectomy Coding
Master ‘separate procedure' rules to perfect your claims. The spleen manages to get in... Read more
Surgical Case:
Nail This Splenectomy Coding Scenario
Take what you've learned in “3 Tips Demonstrate Key Terms You Need to Know for Splenecto... Read more
Here’s Why the Payer Impacts Your Prolonged Service Coding
Only outpatient codes take G2212 or +99217. Depending on your payer(s) for outpatient ev... Read more
Reader Questions:
Decipher Breast Note for ‘Wide Excision’
Question: I'm coding an op report and the surgeon describes the breast procedure as “wid... Read more
Reader Questions:
Respond to MAC Overpayment Claim
Question: We received a “demand letter” from our MAC claiming that we were overpaid. W... Read more
Reader Questions:
Beware Separate Lymph Node
Question: Our surgeon removed tonsils and adenoids for a 6 year old patient. The op report... Read more
Reader Questions:
Implement Mobile Device HIPAA Security
Question: Could you give some tips to help secure our mobile devices, meet HIPAA requireme... Read more
You Be the Coder:
Distinguish GERD Esophageal Procedures
Question: Our surgeon performed a procedure to control the esophageal sphincter to treat a... Read more
Manage Telehealth Compliance and Coding with 3 Tips
Use these resources for clean claims. With hundreds of codes added to the list of service... Read more
Master Modifiers:
Choose Between 52, 53 for Halted Surgery
The devil is in the ‘stopped service' details. When your surgeon has to stop a surgery ... Read more
Practice Management:
Adhere to OSHA COVID-19 Guidelines
Protect back-office staff, too. For employee safety and compliance purposes in your gener... Read more
Reader Questions:
Maximize CS Modifier Use
Question: We've been using modifier CS for Part B claims during the PHE, but I'm not clea... Read more
Reader Questions:
Capture Burn Case Coding Details
Question: Our surgeon treated a 14 year old patient in the emergency room who had a second... Read more
Reader Questions:
Phone Call May Warrant Prolonged Service
Question: Our surgeon performed an E/M service over the phone that lasted 55 minutes. Can ... Read more
You Be the Coder:
Scope Guides Anorectal Biopsy Code
Question: Which code should we use for a case when the surgeon performs an anorectal biops... Read more
CPT® 2021:
Master New Breast Reconstruction/Repair Guidelines
Learn which steps you can separately report. In addition to nearly 20 code changes we elu... Read more
Don’t Miss G Codes Your Surgery Practice May Use
Capture prolonged service pay and more for Medicare beneficiaries. While you're getting u... Read more
Spotlight General Surgery Billing Errors from CERT Report
See specific documentation pitfalls. Medicare Part B claims showed nearly a 3 percent er... Read more
Reader Questions:
Capture ICD-10 Codes Post-Whipple
Question: A patient developed hypoinsulinemia and diabetes after our surgeon performed a W... Read more
Reader Questions:
Expect PHE Through 2021
Question: We're worried about being caught off guard if the COVID-19 public health emergen... Read more
You Be the Coder:
Classify Anus Tag or Hemorrhoid
Question: The patient presented for a colonoscopy and also mentioned a troublesome externa... Read more
CPT® 2021:
Master Lung Biopsy Coding Changes
Use modifiers for multiple specimen extractions. When your general surgeon performs a lun... Read more
Grasp CAA and MPFS Impacts on Your Surgery Practice
There's more to know than E/M. In General Surgery Coding Alert Vol. 23, No. 2, you read t... Read more
Keep Remote Work Secure During Pandemic
Don't let patient privacy lapse. You need to keep patient protected health information (P... Read more
Reader Question:
Use New Prostate Ablation Code
Question: I've heard we can no longer use code C9747, so how should we report prostate abl... Read more
Reader Questions:
Hone Modifier 22 Skills
Question: Is it correct that we should use modifier 22 only if the surgeon documents at le... Read more
Reader Questions:
Look for Medicare Colonoscopy Coverage Change
Question: Is there a change this year in how Medicare pays for colorectal cancer screening... Read more
Reader Questions:
Use Form 3508S for PPP Loan Forgiveness
Question: How can we apply for loan forgiveness under the Paycheck Protection Act? Monta... Read more
Reader Questions:
Find Dedicated Endoscopy Injection Codes
Question: Our surgeon injected India ink to mark a lesion during upper GI endoscopy. How s... Read more
You Be the Coder:
Count Test Order and Review for MDM
Question: If the surgeon bills an E/M visit based on medical decision making (MDM), not ti... Read more
Final Rule:
Prepare Your General Surgery Practice for Big Medicare Pay Decrease
E/M increase won't balance conversion factor decline. The release of the 2021 Medicare Ph... Read more
CPT® Update:
Upgrade Your Vascular Surgery Code Choices for 2021
T-codes and VAD overhaul lead the charge. With major changes to percutaneous ventricular ... Read more
Conquer Colon Polyp Dx Coding for Clean Claims
Treatment decisions rest on accuracy. Missing the correct diagnosis code from your surge... Read more
Reader Questions:
Understand 99072 Opportunities and Limits
Question: We've heard there's a new CPT® code for reporting additional practice expe... Read more
Reader Questions:
Question Hospital Inpatient Telehealth
Question: Can we report inpatient telehealth evaluation and management (E/M) services to M... Read more
Reader Questions:
Dissect Office or Consult E/M Choice
Question: Our surgeon examined a patient in the office and sent a report about the patient... Read more
Reader Questions:
Know When to Use ‘Independent Historian’
Question: Our surgeon evaluated an infant in the office for correction of a birth defect. ... Read more
You Be the Coder:
Peel Back Answers for GERD Evaluation
Question: While performing an esophagoscopy, our surgeon placed a Bravo capsule to monitor... Read more
E/M 2021:
Use This FAQ to Strengthen Inpatient Coding Skills
Time is different in the hospital. Just because you're focused on CPT® 2021's big change... Read more
CPT® 2021:
Update Your Breast Reconstruction/Repair Coding Know-How
Drill down to significant code revisions. With 15 revised codes and two code deletions, p... Read more
Protect Patient Information Beyond the Chart
Understand compliance relief during PHE. Even though you can share patient protected hea... Read more
Reader Questions:
Clarify ‘Correlates’ and ‘Consistent’ Dx Terminology
Question: When I'm assigning a diagnosis code, I'm always confused when the surgeon docume... Read more
Reader Questions:
Select Most Specific EGD Procedure Code
Question: A patient was referred to our surgeon for suspected esophageal cancer or abnorma... Read more
Reader Questions:
Illegible Signature?
Question: What can we do our surgeon's signature is illegible? Oregon Subscriber Answer... Read more
You Be the Coder:
Beware Swan-Ganz Bundles
Question: Our surgeon performed a Swan-Ganz procedure, placed a central line through the s... Read more
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