Advanced Search

Revenue Cycle Insider

Orthopedic Coding:

Don’t Use 2 CPT® Codes When 1 Will Do

Published on Wed May 28, 2025

You’ve reached your limit of free articles. Already a subscriber? Log in.

Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:

Simple explanations of current healthcare regulations and payer programs
Real-world reporting scenarios solved by our expert coders
Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
Instant access to every article ever published in Revenue Cycle Insider
6 annual AAPC-approved CEUs
The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles of

May 2025

Technology & Innovation:
Explore How AI Can Take Items Off Your To-Do List
Jump start your projects with AI analyzing the data. Have you ever wondered how much [...]

Neurology & Pain Management Coding:
Know Differences Before Coding Extremity Ultrasounds
Question: What is the difference between a complete and a limited ultrasound (US) of an [...]

Pulmonology Coding:
Use This Guide to Accurately Code Pulmonary Embolism Diagnoses
Receive a PE condition breakdown. Pulmonary embolism (PE) is a life-threatening condition affecting the patient’s [...]

ICD-10-CM Coding:
Test Your Principal Dx Knowledge With These Scenarios
Find out how to navigate these complicated coding situations correctly. Selecting the principal diagnosis for [...]

Path/Lab Coding:
Don’t Get Tired of Reporting Fatigue Dx With CBC
Question: Is it true that you cannot report fatigue as a primary diagnosis on outpatient [...]

Pulmonology Coding:
Ask Your Provider for Additional Information When It’s Needed
Question: An 80-year-old patient presented complaining of a cough lasting for more than a month, [...]

Emergency Department Coding:
Use This Code for Ganglion Cyst Treatments
Question: If a patient presents with three ganglion cysts on their ankle and foot and [...]

Anesthesia Coding:
Remember These 3 Circumstances to Append GC Modifier
Question: What situations would call for use of the GC modifier? Are there any particular [...]

Path/Lab Coding:
Master Infectious-Agent Coding With These 5 Tips
Don’t forget what the # symbol means in CPT®. When you’re searching for the correct [...]

Path/Lab Coding:
Distinguish Between These Iron Stain Tests
Question: What is the difference between codes 85536 and 88313 for iron stain? Indiana Subscriber Answer: The [...]

Podiatry Coding:
Stand Your Ground on Bunionectomy Coding
Keep your podiatry claims clean and your resources up to date. Bunionectomies are among the [...]

Pulmonology Coding:
Locate the Correct Test Code for COVID, Flu, and RSV
Question: I have a report of a 75-year-old patient with chronic obstructive pulmonary disease (COPD) [...]

Anesthesia Coding:
Don’t Bill These Services Separately
Question: What services are bundled into anesthesia and not separately billable? Oregon Subscriber Answer: According [...]

Orthopedic Coding:
Don’t Use 2 CPT® Codes When 1 Will Do
Question: I have an op note in which the orthopedic surgeon documented fusing the first [...]

Orthopedic Coding:
Remember to Report the Same CPT® Codes for Modifier 62
Question: I am new to orthopedic coding and our providers have started working together on [...]

Primary Care Coding:
Include This Z Code When Reporting Prescription
Question: I work at a primary care provider’s office. A provider saw a patient who [...]

Neurology & Pain Management Coding:
Look to Unspecified Code for This TMJ Disorder Dx
Question: Encounter notes indicate that the pain management (PM) provider treated a patient with “TMJ [...]

Cardiology Coding:
Note CPT® Specifications for ICD Generator Replacement
Question: Do I need an add-on code to report an upgrade of a single chamber [...]

Anesthesia Coding:
Find Answers to These Common Anesthesia Coding Questions
Hint: In anesthesia, MAC can refer to two very different things. Whether you’re new to [...]

Otolaryngology Coding:
Test Your Hearing Test Knowledge With Our Audiologic Function Testing Quiz
Read to the end for a great piece of advice. With CPT® listing so many [...]

Optometry/Ophthalmology Coding:
Spice Up Your Conjunctivitis Coding
Question: A patient presented with severe pain, redness, and excessive tear production in both eyes. [...]

In Case You Missed It (RCI Bonus Content):
2025 Brings New Telemedicine Codes
But only one is reimbursable under Medicare. For calendar year 2025, the American Medical Association [...]

Optometry/Ophthalmology Coding:
Don’t Forget DOS on Your Post-Op Service Medicare Claims
Question: We have been billing for the co-management of cataract surgery post-op services, and every [...]

Primary Care Coding:
Look to Cause, Not Timing on Allergy Dx
Question: A patient presents with complaints of runny nose, sneezing, nasal congestion, and itchy eyes. [...]

Otolaryngology Coding:
Understand Removal or Reduction in This Turbinate Reduction Op Note
Question: Our surgeon documented the following for an in-office turbinate reduction: Starting at the head [...]

Neurology & Pain Management Coding:
Look at Nerve Injected When Coding Destruction by Neurolytic Agent
Refer to 64600-64647 for a complete list of these codes. Destruction sounds intense, but destruction [...]

General Coding:
Structure Your Denial Management Program for Success
Adopting this approach will boost your office’s financial performance. By following the steps outlined in “Seven [...]

Pediatric Coding:
Get the Answers to Your Frequently Asked Immunization Z Code Questions
Hint: Pay attention to ICD-10-CM notes. The difference between coding Z23 (Encounter for immunization) and [...]

General Surgery Coding:
Understand Which Tissues Need to Be Debrided for 11043/+11046
Question: I have documentation for a surgical debridement where the surgeon removed devitalized tissue and [...]

Optometry/Ophthalmology Coding:
Relieve Your Dry Eye Coding Discomfort
Find out what tests physicians use to make a diagnosis. Itchy? Stinging? Burning? Gritty? When [...]

General Surgery Coding:
Does a Cyst Removal Require an Excision or I&D Code?
Question: I’m having difficulty determining if the following surgical documentation supports an excision or incision [...]

Compliance:
Feel Confident When Delivering Audit Results With These Tips, Part 1
Hint: Rely on scope to determine who’s going to see the results. The “A word” [...]

Practice Management:
Avoid a Kick From the Anti-Kickback Statute
Learning the legalities of remuneration could protect you in the long run. Robert Saltaformaggio’s, JD, [...]

General Coding:
Inject These New Codes Into Your Coding Arsenal
Question: Are there any new HCPCS injection codes I should be aware of? I feel [...]

Otolaryngology Coding:
Look to Etiology for Definitive VPI Dx
Question: What is the correct way to code for an augmentation pharyngoplasty for a diagnosis [...]

Urology Coding:
Learn How to Approach Prostatectomy Coding – Part 1
Learn the difference between subtotal and radical procedures. As a urology coder, you should be [...]

Diagnostic Radiology Coding:
Learn the Definition of a Hyperechoic Pancreatic Mass
Question: I have a radiology report for an ultrasound (US) on a 40-year-old patient. The [...]

Cardiology Coding:
Pay Attention to Septic Embolism Code First Notes
Question: A cardiologist at my practice documented that a patient with infective endocarditis developed a [...]

Neurosurgery Coding:
Use This Code Trio When Choosing Hypotension Dx
Question: If a patient has intracranial hypotension, is there a single diagnosis code to represent [...]

Neurosurgery Coding:
Get the Jump on July T Codes
Question: I remember a reader question in RCI recently that referenced Category III codes, also [...]

General Surgery Coding:
Code Cholecystectomy Surgeries With Confidence
Pay attention to NCCI edits before reporting additional procedures. In the U.S., approximately 20 million [...]

E/M Coding:
Incorporate These Strategies Into Your Provider Education
Common sense: Adapt your educational content to your audience. Teaching providers about evaluation and management [...]

Neurosurgery Coding:
Check Complexity, Brain Area on AVM Repairs
Remember to check for separately codeable services, too. When your neurosurgeon treats a patient with [...]

Primary Care Coding:
Take This Advice for Seamless BHI
Here’s how to bring everyone together to streamline services and improve patient outcomes. If you [...]

Emergency Department Coding:
Remember 3 Dx Codes for This CKD/Hypertension Patient
Question: The emergency department (ED) provider performs an evaluation and management (E/M) service for a [...]

Gastroenterology Coding:
Can You Assign Z86.- As a Primary Diagnosis Code?
Question: A patient with a history of adenomatous colon polyps came in for a screening [...]

Podiatry Coding:
Crack the Code on This Cuboid Case
Question: A patient was seen at our practice for treatment of a displaced fracture of the [...]

Medicare Regulations:
Find Relief in G2211 Update
Question: My provider wants me to bill G2211 alongside a Medicare annual wellness visit. Can [...]

Diagnostic Radiology Coding:
Examine This Comprehensive Guide to Spinal Myelography Codes
Pay attention to spinal region when coding myelography. Conditions affecting or centered around the patient’s [...]

General Coding:
Don’t Bill Transfer of Care Within the Same Global Group
Question: I work for a group of surgeons. I have a patient who underwent a [...]

Compliance:
Utilize Separate Notes
Question: We sometimes see patients who come in for services relating to incidents involving workers’ [...]

Technology & Innovation:
Another Day, Another Cybersecurity Breach in Healthcare
Question: The ransomware attack on Change Healthcare in 2024 shook the healthcare industry, and made [...]

Podiatry Coding:
Button Up This Tailor’s Bunion Procedure
Question: I need help coding the following operative report: “4 cm linear incision placed over [...]

E/M Coding:
Expect Denial When Reporting 2 E/M Services on Same DOS
Question: One of our physicians saw a patient in the morning, and then again in [...]

Cardiology Coding:
Get Into the Technicalities When Coding Cardiovascular Wearables
Hint: You need to know whether a service provided is global or a component. When [...]

Practice Management:
Keep This HIPAA Expiration in Mind
Question: I’ve observed that our patient documents related to HIPAA are only valid for one year [...]

Orthopedic Coding:
Coding Finger Fractures Doesn’t Have to Be Daunting
Remember the difference between open and closed fractures. Finger fractures are a common orthopedic injury, [...]

Pediatric Coding:
Sequence These Diagnoses Correctly
Question: Our pediatrician saw a patient who came in after having several days of low-grade [...]

Compliance:
Understand What Receiving Kickbacks From EHR Vendors Looks Like
Question: Our practice uses a vendor to provide and maintain the infrastructure of our electronic [...]

Gastroenterology Coding:
Get to the Bottom of This EGD and Botox Injection Coding Mystery
Question: I have a procedure report for an esophagogastroduodenoscopy (EGD). The gastroenterologist performed the EGD [...]

Emergency Department Coding:
Monitor Method, Size, and Depth When Selecting Debridement Codes
Remember add-on codes when additional surface area is addressed. When patients come to the emergency [...]

ICD-10-CM Coding:
See When Signs and Symptoms Require a Query
Question: My provider recently saw a patient displaying symptoms of nausea, vomiting, and discomfort in the [...]

Ob-Gyn Coding:
Learn Why You Should Report Q0091 for Pap Smears
Question: I was hoping to get some clarification on the Pap smear code Q0091. I [...]

Oncology Coding:
Let This NCD Be Your Guide to Correct CAR-T Administration Billing
Question: Our providers are trying to bill CPT® code 38228, and the claims are continuously [...]

Oncology/Hematology Coding:
Take on These Common Oncology Coding Challenges
Make sure you avoid these interpretation errors. Oncology coding is a critical component of the [...]

Urology Coding:
Use Modifier 59 to Report Separate Biopsy and Stent Placement Procedures
Question: A urologist used cold cup biopsy forceps to biopsy a lesion on the left [...]

Diagnostic Radiology Coding:
Turn to the Radiology Report to Further Specify a Diagnosis
Question: I have a report where the emergency department (ED) physician diagnosed the patient with [...]

E/M Coding:
Don’t Upcode This Low-Level Follow-Up
Question: I’m coding a follow-up encounter for a patient who experienced a neck injury during a [...]

Technology & Innovation:
Deliver Continuous Chest Compressions in Emergencies
Question: Emergency medical technicians (EMTs) often arrive at our emergency department (ED) with patients who [...]

Medicare Regulations:
Distinguish Redetermination From Reconsideration
Question: What’s the difference between a redetermination and a reconsideration, in terms of Medicare? Wisconsin [...]

Oncology Coding:
Sequence These 2 Codes for Myxofibrosarcoma IMRT
Question: A patient came in for intensity-modulated radiotherapy (IMRT) to treat myxofibrosarcoma of the left [...]

ICD-10-CM Coding:
Don’t Miss Delirium Code in This UTI Scenario
Question: A provider documents that a patient has delirium due to an acute urinary tract [...]

Urology Coding:
Does 51102 Require a Laterality Modifier? Find out
Question: We have a claim that was returned with a code denial. Originally, we submitted [...]

Medicare Regulations:
Stay Updated on Fast-Tracked Price Transparency
Find out what the president’s executive orders may mean for your organization. On Feb. 25, [...]

Ob-Gyn Coding:
Can an Ob-Gyn Report a Preventive Code the Same Day As an E/M Visit?
Tip: Don’t use 99401-99404 if the patient is sick. Fact: You can report preventive medicine counseling [...]

Pediatric Coding:
Look to Age for Colic Dx
Question: One of our pediatricians saw a 4-month-old patient and reported that the patient is [...]

Practice Management:
Don’t Get Caught Billing ‘Improbable Time’
Question: A colleague of mine who works as a coder at another location of the [...]

Ob-Gyn Coding:
Know What to Do If a Baby is Born at Home
Question: A patient was seen by a clinic for their entire pregnancy, but they had [...]

Gastroenterology Coding:
Capture Capsule Endoscopy Procedures on Your Claim
Learn if incidental visualizations can be reported separately. Capsule endoscopy is a medical procedure that [...]

View All