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  1. J

    Question Bone grafting of the femur and tibial tunnels CPT code

    I need help with coding the following procedure as soon as possible: Preoperative Diagnosis: INSTABILITY RIGHT KNEE Postoperative Diagnosis: INSTABILITY RIGHT KNEE Procedure Performed: Bone grafting of the femur and tibial tunnels as a stage procedure for future ACL reconstruction...
  2. J

    Question Sigmoid Granulomatous Mass

    Help is needed on how to code this. PATIENT IS BROUGHT TO THE OR ON 9/19/19 AND PLACED ON TABLE SUPINE POSITION. AFTER ADEQUATE GENERAL ANESTHESIA, SHE HAD A FOLEY CATHETER PLACED AND WAS PREPPED DRAPED STERILE FASHION. AN INFRAUMBILICAL INCISION WAS MADE AND A 5 MM BLADELESS TROCAR WAS...
  3. J

    Question Revision of Fundoplication code

    Our surgeon took his patient back to surgery to do a revision of a fundoplication. He removed some stitches to allow the fundoplication to open and did a dilation of the esophagus. I have CPT code 43450 for the dilation but I have no idea how to code the stitch removal. The OP note is below. If...
  4. J

    Question Percutaneous pinning of Hammertoe

    Thank you so much Ashley. That makes sense and if it is for all corrections than I will use that code!
  5. J

    Question Percutaneous pinning of Hammertoe

    I am not sure how to code this procedure and hopefully someone can help! Preoperative Diagnosis Hammertoe deformities bilateral feet in the 2nd, 3rd, 4th, and 5th toes Procedure Performed Closed reduction and pinning of the bilateral 2nd, 3rd, 4th toes Indications Patient with rigid...
  6. J

    Foreign body foot

    If there is no incision than you can't code any of the incision codes. How was it removed - tweezers? If it wasn't done by any incision it should be included in the E/M code and not billed separately.
  7. J

    Question Lower extremity procedure codes

    Thank you! That does help!
  8. J

    Revision of Fundoplication code

    This was a stitch removal to revise the previous surgery as the patient was having issues. The surgeon did this to alleviate his dysphagia after the surgery. Would you still consider this included in the previous surgery? This is not a normal part of the previous surgery.
  9. J

    Question Diagnostic Lap or Discontinued Lap Chole

    I would code it 47562-53.
  10. J

    Question Diagnostic Lap or Discontinued Lap Chole

    From what the note says it looks like he did more than just a diagnostic lap as he tried to take down the adhesions, etc. It also stated that the procedure was aborted. I would code it as a discontinued lap chole.
  11. J

    Question Lower extremity procedure codes

    I always get confused with these procedures done in arteries as to what is being done and what CPT codes to use. If someone could look at the OP note below and help me with the codes for what was done I would appreciate it! Also if anyone knows of a source I can turn to so I can understand these...
  12. J

    Revision of Fundoplication code

    Our surgeon took his patient back to surgery to do a revision of a fundoplication. He removed some stitches to allow the fundoplication to open and did a dilation of the esophagus. I have CPT code 43450 for the dilation but I have no idea how to code the stitch removal. The OP note is below. If...
  13. J

    Question Repair of External Iliac Artery

    Thank you Vicky! That is what I was looking for!
  14. J

    Question Repair of External Iliac Artery

    My surgeon was called into a surgery to repair the External Iliac Artery accidentally cut by the surgeon performing the intended surgery. I am trying to find a code for this procedure and am not sure what code to use. If anyone can help with a code it would be appreciated!! REANASTOMOSIS OF...
  15. J

    Bone allograft to tibial and femur tunnels staged for future ACL reconstruction

    Any ideas on the correct coding for this procedure would be greatly appreciated! I have searched for an answer in other threads but do not see a definitive answer! Someone out there must have had one of these surgeries!! If I have to use an unlisted code, then with what code would this be...
  16. J

    Arthroscopic shoulder procedure questions

    Thank you very much for your prompt and helpful response! Do you have an idea of what code to compare the 29999 to? I will definitely check those articles out!
  17. J

    Arthroscopic shoulder procedure questions

    Hi All! I am trying to figure out how to code some arthroscopic procedures and the more I try to figure it out the more I am confusing myself! :confused: If some one could help explain this to me it would be appreciated!! First - if the doctor does a subacromial decompression along with other...
  18. J

    Can wound care be billed after patient is discharged but returns within global?

    90 days is the global for the procedure. If this is related to the amputation - which it sounds like it is, then it would not matter if the doctor declared the toe healed. Apparently it was not as healed as he thought! :rolleyes:
  19. J

    sentinel lymph node biopsy followed by lymphadenectomy???

    The above options are answers for 2 different surgeries. Did the surgeon perform a mastectomy or just the lymphadenectomy? According to your question, there is no mention of a mastectomy - so option number 1 would not apply. If all he did was the lymphadenectomy following the biopsy - then...
  20. J

    Help with correct CPT codes!

    I'm looking for some help with this surgery...vascular procedures confuse me! I have looked at codes 34203, 35302 & 35666 for the vascular surgery. I am not sure if I am looking at the right codes or if the documentation is clear as to the areas or if any of these are bundled. If I could get...
  21. J

    Help with correct codes for this vascular surgery

    I'm looking for some help with this surgery...vascular procedures confuse me! I have looked at codes 34203, 35302 & 35666 for the vascular surgery. I am not sure if I am looking at the right codes or if the documentation is clear as to the areas. If I could get some answers, as well as some...
  22. J

    Laparoscopic resection of colon polyp

    Thanks for your answer. I think I will try this and hopefully it will not get denied for medical necessity as the last time I coded this scenario. :)
  23. J

    Debridement to bone with advancement flap

    Code 15937 is for Sacral ulcer. Code 15946 is for Ischial. I am not an expert on skin procedures but I would use 15946 with 15734. Other opinions might be more helpful.
  24. J

    Laparoscopic resection of colon polyp

    Any ideas on how to code this procedure? Preoperative Diagnosis Adenomatous polyp of right colon _ Postoperative Diagnosis Same _ Procedure Performed Laparoscopic resection of colon polyp Indications Recurrent adenomatous polyp that could not be resected endoscopically The patient...
  25. J

    Mastectomy coding

    38900 is the add on code used for the nonradioactive dye injected into the area used during a sentinel node procedure. If this is not done, then I would not use this code. The radioactive tracer injected by the radiologist is different. 38900 Intraoperative mapping may be utilized during lymph...
  26. J

    How do you code a umbilicoplasty with hernia repair?

    I need some help coding this surgery. The doctor did an umbilical hernia repair with an umbilicoplasty. There is no code for the umbilicoplasty. How would I code that part of the procedure? Would it be included in the hernia repair code? I've seen some suggestions to use 15830 and 15847, however...
  27. J

    Subchondral bone graft surgery code??

    Any idea what the CPT code would be for this procedure? I was thinking 27415 but it does not appear to be a open procedure. And 29867 is Arthroscopy, which I don't see in the note! All help is appreciated! Preoperative Diagnosis Subchondral fracture lateral femoral condyle/medial tibial...
  28. J

    Muskoskeletal vs extremities

    I also do see that there is documentation to support 8 systems. However, just take note that whether they state musculoskeletal or extremities as the heading it is what they document under there as to what can be counted. As in your example above, under extremities your doctor has documented not...
  29. J

    Table of risk

    When the table of risk refers to with or without risk you need to look for documentation that the patient has conditions that would make that procedure/surgery more risky than for another person without those conditions. It does not refer to the doctor stating "I explained the risks of bleeding...
  30. J

    Cardiac Cath MDM

    That would depend on whether there are any identified risk factors. If no identified risks, then it would be moderate. If there are identified risks, then it would be High.
  31. J

    Obturator hernia

    I would use the unlisted code 49659. It is definitely not the code for an inquinal hernia!
  32. J

    Reference guide for general sx coding

    I like to use Coders" Desk Reference for Professional Coders. I find these descriptions of the codes to be very helpful. I also do like Supercoder, however my job does not have accounts with them.
  33. J

    Question on diagnosis codes

    I code each encounter as documented - each document stands alone. If the doctor did an H&P and stated the patient had acute cholecystitis or even just abdominal pain, then that is what I would code from the H&P, not what was documented on another note. Once he does the surgery and makes the...
  34. J

    CPT Coding

    If the new provider sees one of his old patients that were seen by him in any other practice or facility within the 3 year period, regardless of tax ID, the patient is considered an established patient with his new practice. So, I would think in this case it would be considered global to the...
  35. J

    Any ideas on CPt codes for this procedure?

    Thanks for pointing me in the right direction! I think I will go with code 43332 however because the incision was midline and not thoracoabdominal. :D
  36. J

    CPT coding for Open Right colectomy with end ileostomy

    Can you post the redacted note? It would be helpful to answer your question.
  37. J

    Prophylactic Removal of Breast

    What codes did you use to bill for the surgery? What was the denial reason?
  38. J

    Any ideas on CPt codes for this procedure?

    PREOPERATIVE DIAGNOSIS: Recurrent gastric volvulus and hiatal hernia. POSTOPERATIVE DIAGNOSES: 1. Recurrent gastric volvulus and hiatal hernia. 2. Serosal tear. PROCEDURE: Exploratory laparotomy reduction of gastric volvulus and hernia and gastropexy and gastric ligation. FINDINGS...
  39. J

    Not sure how to code this! Need help fast!

    Thanks for your help!! :D
  40. J

    Not sure how to code this! Need help fast!

    Any answers to this? I am still hoping someone can supply some suggestions on this!! :-)
  41. J

    BCBS Audit - Help Needed

    Based on what you are saying this sounds like some type of harassment! Where I worked previously we dealt with Horizon BCBS and they were hard to work with. Our hospital actually dropped their participation with them - and they were located in NJ. They only resumed a contract with them when we...
  42. J

    What codes for this procedure?

    I posted this in General Surgery but have not gotten any help, so I am re-posting here hoping someone may have suggestions! Thanks, I am not sure what codes to use for this laparoscopic procedure! If someone could please review this OP note and help it would be appreciated!! So far I have...
  43. J

    Not sure how to code this! Need help fast!

    I am not sure what codes to use for this laparoscopic procedure! If someone could please review this OP note and help it would be appreciated!! So far I have tentatively used unlisted codes 47379, 44238 and 47562-52 for the cholecystectomy attempt. I am not sure if I am looking at this correctly...
  44. J

    How would you code a failed knee replacement - patellar component

    I am having trouble coming up with what CPT codes I should use for this surgery 27488, 29874, 29876, etc. - I am just not sure which of these if any! The patient was brought to the operating room theater, placed supine upon the operating room table after satisfactory general endotracheal...
  45. J

    Failed knee replacement

    I am having trouble coming up with what CPT codes I should use for this surgery 27488, 29874, 29876, etc. - I am just not sure which of these if any! The patient was brought to the operating room theater, placed supine upon the operating room table after satisfactory general endotracheal...
  46. J

    New Patient E/M PFSH

    No. In order to count any part of the PFSH the provider would have to document something for each element. Such as: Personal history - patient has Diabetes; Social history - patient is non-smoker, lives with family; Family - no family history of lung cancer. It is also no appropriate to say...
  47. J

    HELP - -MDM Points - pt seeing different providers at same practice

    For MDM points, I would count this as a new problem for the second provider. I would suggest that this provider document that this is the first time they are seeing this patient for this problem. The description in the box under A says "new problem (to examiner)" and we were instructed by our...
  48. J

    E/M Question

    You cannot use the 25 modifier in this case. Guidelines tell you that if a patient is seen in the office and then seen in the hospital as inpatient on the same day you only bill the inpatient E/M - all other work is combined with that visit. Even if they see a different provider than seen in the...
  49. J

    Closed fracture treatment

    The doctor should only bill the E/M visit. If he has no intentions of following up on this patient and he hasn't followed the patient in the hospital, then he provided no fracture care. If he did any kind of casting he should only bill for that, but not a global fracture care code.
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