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    Help Needed! Coding off EKG & X-Rays

    I have read where coders aren't allowed to code off the EKG or x-ray report and we can only code the diagnosis after it's been read by the treating physician. Example: Dr. A, who is a Cardiologist, reads an EKG in the ER. He states in his report, the patient has an AV paced rhythm with a...
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    HELP!! Radiology/EKG Coding

    I am new to radiology coding and I need some clarification. Here is the scenario: A patient, who is an inpatient, is experiencing shortness of breath. The physician orders a chest x-ray. The radiologist reports in the impression that opacities and pleural effusions are seen. Do we code the...
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    MDM Sufficient?

    One of the physicians I code for has very minimal progress notes. They're generally follow ups for a broken bone or injury. He usually has 1 HPI point, no ROS and no Physical Exam. For the MDM (assessment), he writes: F/U (follow up) or F/U in 3 weeks. That is it, nothing else. Is this enough...
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    Opthalmology Help!!

    Ophthalmology Help!! I just started coding for an Ophthalmology practice and I gotta admit, I'm a little lost. How do I know when to bill for the CPT Eye codes (92002/92004/92012/92014) vs E/M codes? Is there a simple rule to follow? Please help!! Thank you!
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    Optometrist and Ophthalmologist New/Est Patient

    I need some clarification, please. If an Optometrist and an Ophthalmologist are in the same practice, they are considered to be under one "umbrella", correct? For instance, a patient sees an Optometrist for the first time. That Optometrist bills a new patient E/M code. The patient returns...
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    Remote Employment

    I'm a CPC but at my previous job, I worked denials, wrote appeals, called insurance companies, etc. Does anyone know of any companies that hire remotely for a position like that? Thank you in advance for your response.
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    Colonoscopy -the transverse colon

    I have a case where there was a biopsy and polyp removal from the transverse colon. Are we still able to bill 45385 & 45380-59 even though both procedures were in the same area of the colon? FYI...The biopsy was to confirm if the patient had Crohn's disease. Thank you in advance!
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    CPT code? - The physician performed

    The physician performed an open exploratory laparotomy but noticed the pancreas was "inflamed with a lot of surrounding fat saponification" so she drained it. She also noted that there was no active bleeding and the pancreas was not necrotic. In the deifinition for exploratory laparotomy it...
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    Inpatient Coding

    This may seem like an elementary coding question but I'm not an inpatient coder so I need some guidance. I have a physician who admitted a patient in observation on 08/27/14 (at 10 pm) but his H & P is dated 08/28/14. He discharged the patient on 08/28/14. Which date should I go by, the 27th...
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    Please help!!

    Any ideas on how a laparoscopic removal of an intraabdominal 6 cm lipoma would be coded? :confused: I would really appreciate any thoughts on this one!! Thank you!!
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    Please help!!

    I have a rather unusual situation. My physician is listed as a co-surgeon for 2 procedures- 11606 & 12035. Modifer -62 is not allowed for these procedures. It was suggested to me that I should bill an intraoperative consultation. Would it be acceptable to do that? :confused: My physician can't...
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    Postoperative N/V billable in global period?

    A patient had a hernia repair. He had to remain in the hospital a few extra days because of postoperative nausea & vomiting. He was discharged but then returned the next day due to postoperative nausea & vomiting. The physician is trying to bill an inpatient admit, subsequent hospital visit &...
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    Mulitple Internal Hernia Repairs

    My physician performed two internal hernia repairs: "One was via the jejunal mesentery at the level of the jejunal anastamosis and the second was under the Roux limb at the level of the transverse colon." Would this qualify for two internal hernia repairs or just one? Any help would be greatly...
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    De la May Procedure

    My physician performed what he called a "de la May" procedure on a patient who had a rectal prolapse. I have researched this procedure and found nothing on it. Does anyone know what it is and the CPT code? I'm leaning towards 45123 but I'm not sure. Thank you in advance for your help! :)
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    Repeat Cholangiogram

    I have an unusual situation. The physician performed a cholecystectomy with a cholangiogram. He had to perform another cholangiogram during the same operative session due to a stone that was thought to be in the common bile duct. This was coded as 47563 and 47579 (unlisted laparoscopy procedure...
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    Advancement Flaps

    My physician removed excess skin and performed 2 advancement flaps measuring 1150 cm2 each. Advancement flaps get me every time. I came up with 15830 (for the excess skin removal), 14301 & 14302 (with 75 units). Does that sound right to anyone? I need to know if I'm on the right track on this...
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    Any thoughts on this one?

    I have a patient that had a cholecystectomy. The physician that performed the surgery is trying to bill for the inpatient subsequent days following the surgery. The patient developed a leak from his drain. They did not know for days if it was from bile or ascites. One of the physicians said that...
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    Colostomy take down

    Does anyone know if a colostomy take down is billable with a rectosigmoidectomy? I've researched this one and can't find anything that says it is billable or isn't billable. Thanks in advance for you help! :)
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    Gallbladder Removal

    My physician was trying to repair a duodenal ulcer. He opened the patient and found her gallbladder was adhesed to the stomach. As he was trying to remove the adhesions off the gallbladder, he damaged the gallbladder wall. At that point, he felt as if he needed to remove the gallbladder. Can he...
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    Replacement of MediPort

    I am in need of advice. The physician replaced a MediPort (catheter and port). I am thinking the only code to be reported should be 36582. The hospital, however, is reporting 36582 and 36590 (removal, with pump, central or peripheral insertion). This was performed through the same incision but...
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    Need some advice!

    I need someone else's thoughts on this one.... The patient was admitted to the hopsital. Dr. A was consulted to see him. Dr. A only has an extremely brief note dated 09/05/13 basically stating the patient's principal problem and the surgery that will be performed by him, nothing else. Not an...
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    Conditions within the global period

    Could any one please tell me where I can find a listing or something that says exactly what is included or not included in the global period while the patient is in the hospital? My physicians are always trying to bill E/M's when the patient is in the global period. I know complications are not...
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    Open Hemigastrectomy CPT code needed

    I need a CPT code for an open hemigastrectomy with wedge resection of stromal tumor. I found 43631 but it includes gastroduodenostomy, which was not performed. The tumor was at the mid gastric level. Should I put a -52 on 43631 since a gastroduodenostomy wasn't performed or is this an unlisted...
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    Please Please Help!!

    This, for me, is a head scratcher. How would you code this? I don't know if I'm missing something or this is poor documentation. Any help would be greatly appreciated!! Thanks!!! PREOPERATIVE DIAGNOSES: Wound dehiscence with chronic wound infection, postoperative. POSTOPERATIVE DIAGNOSES...
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    Hernia repair included?

    The patient had emergency surgery to repair a perforated peptic ulcer. The physician mentioned in his op note that a supraumbilical hernia was repaired at the time of surgery. He does not mention the hernia in the H & P. I was thinking 43840 & 49905 but I'm not sure if the hernia repair is...
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    Abdominal Wall Hematoma

    I need some assistance on this one. The physician told me the area he debrided was 30 cm x 20 cm. I was thinking 11042 & 11045 x 29? I don't know if I'm way off base on this. Thank you so much in advance for your help! Operative note: PREOPERATIVE DIAGNOSES: Right lower quadrant anterior...
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    Please help!! Am I thinking right one this?!

    Please help!! Am I thinking right on this one?! :confused: I am stumped on this one. I'm thinking 44899 and 44120. Please, please help!!! Op Report: PREOPERATIVE DIAGNOSES: 1. Gastrointestinal bleeding. 2. Possible Meckel's diverticulum, distal small bowel. POSTOPERATIVE DIAGNOSES: Large...
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    Same Specialty Discharge

    A patient had a hernia repair performed on 09/27/13 by Dr. P who is a general surgeon. Dr. S, who is also a general surgeon within the same practice as Dr. P, is trying to bill the patient's discharge on 09/28/13. Can Dr. S bill the discharge? I'm thinking not because he is in the same practice...
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    Open Omentectomy with Laparoscopic Hernia Repair

    I'm unsure if the open omentectomy is separately billable. Any help would be greatly appreciated. DESCRIPTION OF OPERATION: The patient was prepped and draped in the usual sterile fashion after satisfactory achievement of anesthesia. We went ahead and did a cutdown in the left upper quadrant...
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    Colostomy - I need some help!!

    I need some help!! Below is the op report: OPERATION: Debriding colostomy. DESCRIPTION OF OPERATION: The patient was prepped and draped in the usual sterile fashion. There was an old colostomy site on the left side and it appeared on computed tomography (CT) scan that the colon was very...
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    Excision of Sinus Tract

    I need some help with this one. Any help would be greatly appreciated! Op Note reads: Pre-op Dx: Chronic draining sinus tract, old midline abdominal incision. Post-op Dx: Retained chronically infected suture. Op Preformed: Exploration of anterior abdominal wall with removal of foreign body...
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    Physician billing for Chest Physiotherapy

    My physician, who is an allergist/immunologist, is wanting to know if he can bill for chest physiotherapy (CPT code 94667). I have not had any luck finding any information about this. I have seen where physical therapists and respiratory therapists can bill but nothing about physicians. Any...
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    Debridement Surgery Help Needed

    I need a little bit of help. I am unsure of how to code the following op report: "The patient had a large 10 x 10 cm, necrotic, deep sacral decubitus. A skin incision was made with a 10-blade scalpel, excising the necrotic eschar. There was foul-smelling pus beneath the eschar, and there was...
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    New pt or Est pt?

    A patient came in to see the general surgeon on 12/06/11 and had a unilateral duplex scan of the extremities done (CPT code 93971)....no office visit was billed. The patient came back into his office on 01/03/12. Would she be considered an new patient or established patient? I'm leaning towards...
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    Pathology diagnosis

    Does anyone have any ideas on which diagnosis code(s) I could assign for this? According to the Pathology Report, the pathology on the chest wall lesion specimen is described as "Infiltrating poorly differentiated carcinoma consistent with infiltrating mammary carcinoma" Thank you in advance for...
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    Albuterol/Pulmicort Combination Drug

    My physician is wanting to know if there is a HCPCS code for an Albuterol/Pulmicort drug. Is there a combo HCPCS drug? I haven't been able to find one but I thought I would ask in case there is one. Thank you in advance for your help! :) ~Lisa Lott, CPC
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    Medicare Colonoscopy Rules

    I do not know if this question has been posted before...forgive me if it has but I can't find an answer anywhere. I have a claim that was denied by Medicare because G0121 (DOS 04/06/11) was billed a little over a year from when 45378 was billed (DOS 03/12/10). The denial states "benefit maxmium...
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    Jugular Vein Aneurysm CPT code

    Hello everyone. I have a question and I hope I can get some thoughts or advice on.... Our surgeon performed a jugular vein aneurysm resection. We billed out CPT code 35201 because that was the closest code we could find to describe what he did. Well, I received a denial from Humana that stated...
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