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  1. L

    Biopsy CPT 11100 vs: 113xx

    I also agree with the physician. Consider that they mean the documentation does not support the medical necessity of the charge. Was the excision you mentioned at a separate site? are they trying to bundle the two?
  2. L

    Annual eye exams

    There are specific codes for eye exams, but MANY eye docs are now billing the E&M codes because of the better reimbursement. As soon as there is any sort of medical dx, they usually do this (e.g. headaches, diabetes...). I have annual eye "wellness" exams for a $10 copay, but with my previous...
  3. L

    Tumor or lesion removal?

    I am leaning toward the tumor excision code (musc/skel section) because it sounds like sub-q tissue.....but waiting on the path report can certainly help with your code decision!
  4. L

    Fat Graft to face

    Hello! Surgeon is excising a cyst off mandible and will take a piece of mandible as well. He will be harvesting a fat pad from the abdomen to fill space of excision. Is this separately billable or considered part of closure? Looking at 20926 for graft, but not finding anything for placement of...
  5. L

    I'm trying to become an auditor

    It really depends on who is hiring and what they require. Obviously a degree is helpful, but I became an auditor without a college degree, based on my years of experience in coding. Someone gave me a chance and I ran with it. I eventually added coding credentials, (E&M, Compliance) and I am...
  6. L

    ICD 10 training

    Best guess, without a complete scenario, is that they left off the dehydration because they are assuming it to be a symptom of the Salmonella. Guidelines tell us not to code symptoms when they are a known part of a condition.
  7. L

    vasectomy coding

    Not likely. How was the vasectomy done? You will usually use only one method/code.
  8. L

    reduction in payment

    there should be no reduction, but your global period will start over.
  9. L

    I&D Groin Wound

    Sounds like the intent was more like an excision than a debridement to me. I would likely use a benign excision and a intermediate repair code.
  10. L

    Medicare Denied a Fluroguide 77001-tc but paid 36561 for port

    Ae you sure you don't need a 26 on the 77001? if the physician was using the images for guidance, that is likely the modifier you need.
  11. L

    pre op

    Is this the same doctor who will be performing surgery? Has the decision to operate already been made?
  12. L

    Facility billing with TC/26

    I'm not experienced in outpatient/facility coding but need help with a question. How do you bill for procedures when there is a TC/26 involved? For example, a specialist see's a pt in out outpt clinic and orders an EMG. HE reads the EMG. The hospital billing department needs to bill the...
  13. L

    Global billing

    We post them internally only with the zero charge, and put them to patient responsibility so a claim will not generate.
  14. L

    What is included in a well woman?

    Are you talking commercial or Medicare? Medicare has a list of 11 elements and you must do at least 7 to bill the G0101 code (Don't forget the Q0091 if you collect a pap)...
  15. L

    medicare preventative wellness exam

    If they have had there IPPE (Welcome to Medicare exam), you can bill a G0438, and once they have there G0438, then yes, every subsequent wellness exam will be a G0439. We use V70.0 as our primary dx code. You might want to check with your Medicare carrier to see if they have another preference...
  16. L

    Dermabond - HCPCS code

    If you are billing this with an OV or a simple repair code it would be inclusive/not separately billable.
  17. L

    99215 Documentation/99213 Appropriate

    Actually, I don't think she is wrong. Remember you only need two of the three key components. Truth is you shouldn't code higher than the MDM, but you can, and that is what the EMR systems are doing. Obviously its not "right" ethically to do so, and the MDM should drive your code selection...
  18. L

    Colon resection

    You are correct that you cannot bill the scopes when they are part of a larger surgical procedure. This comes from the CCI rules.
  19. L

    authorizations in the physician office.

    You cannot upcode based on time spent by nurses on the phone. E&M codes are based on specific criteria as laid out in the CPT book, and the 95 and 97 guidleines. This is just part of practicing. Is there a way to streamline the auth process? Have one dedicated employee to do them all? Are your...
  20. L

    Annual Wellness Exams

    G0438 is for the first visit, even if the patient is established with your doctor. Every year after that he will use the G0439. Please feel free to contact me directly if you have further questions, I would be happy to help you :)
  21. L

    medicare PE

    if it is a preventive pap/pelvic, then consider the G0101 / Q0091 codes- BUT there are specific guidelines on what needs to be done for this. Also, Medicare covers an annual wellness visit (AWV) G0438 and G0349...but unless your doc KNEW he was doing that- sending it back will probably do no...
  22. L

    Critical Care and Initial hosp care same day

    You can bill both, but only is pt was admitted first, and then later needed the critical care. I don't think this was the scenario you presented though. (but for future reference! :D) i just found this on our MAC site in the Q&A: Q7. A patient presents to the emergency room. The physician...
  23. L

    Reduction of small bowel obstruction

    It's hard to say without seeing an op report. Is there anyway you can post exactly what was done? It almost ssounds like a repeat hernia repair, where the reduction was part of the repair.
  24. L

    HPI statement "Patient Feels Fine"

    I'm curious what the cheif complaint is...and if the patient feels fine what the purpose of the visit is. If it is a follow up to something, and that was all i had, I would give 1 HPI element of quality.
  25. L

    Exam Level

    I have worked with gen surg for quite a few years now, and this has always been the case- even before EMR. One reason is that if this patient will be needing surgery, then the hospital will require an H&P, and so this note will serve as that as well. If I were going to do surgery on someone I...
  26. L

    Hospital visits

    No. The work/documentation fo the two visits would be combined for one code.
  27. L

    Codes for Medicare Weight Loss Counseling?

    I've attached a cheat sheet that I made for my docs. Hope it is helpful to you!
  28. L

    Regarding excision of Lipoma

    For the most part, lipomas are coded from the musc/skel section- depending on the operative note of course. Simple closure would be included. You gave a scenario of 6 lipomas costing about $16K, for us, it would be closer to $4000 total. Seems like your fee's are extremely high. Of course I am...
  29. L

    59 and 51

    51 is used for multiple procedures. 59 takes its place when CCI edits tell you you cannot bill the codes together, but your documentation proves they are separate. They will not know the CCI edits if they do not have access to them, or look them up. I get the coding rule, but for the surgeons...
  30. L

    AWV with prostate exam

    They shouldn't bundle, nor should you need a modifier. I'd give them a call.
  31. L

    Hpi

    Agree. pain seemd like the CC here. would just need one word...severe...pulsating...etc.
  32. L

    Medicare and code 99214

    I haven't seen any problems with anything getting paid. :confused:
  33. L

    coding help - breast augmentation

    What is the code the plastic surgeon uses for the initial procedure that the fills fall under? Are you doing all the "post op" care? Can you bill that code with a 55 modifier? Why are you guys doing it and not him? are you covering for him? maybe a financial agreement should be made with him...
  34. L

    Coding Help

    The duodenum is part of the small intestine. was this done open or laparoscopically? Without an op report I can only provide suggestions, but you might want to take a look at 44010, 44110, 44120 or 44202
  35. L

    Lifeport

    I've never heard of a "lifeport". What is it and what exactly is he doing?
  36. L

    Bariatric Center

    I would agree that these should be billed with a 22. And yes, the "outpatient" POS code will cause higher copays and deductibles for many patients. If there is any way to let them know up front I would do so. We have the same issue here with specialists coming in to use hospital space to see...
  37. L

    Need help with lcd: Medicare & medicaid

    I think you mean G0434. http://blogs.aafp.org/fpm/gettingpaid/entry/drug_screening_codes_have_changed this may help
  38. L

    Question for E&M Codes

    Patricia, email me at lvargas@cassregional.org I have a few resources/articles, etc that may help.
  39. L

    mod 25

    Per Medicare "The initial evaluation is always included in the allowance for a minor surgical procedure" https://www.cms.gov/manuals/downloads/clm104c12.pdf See section 40.1 There is no yes or no answer to your question, because it would depend o the documentation and what exactly was done...
  40. L

    E/M with mom of an established patient

    Unfortunately there is no clear cut answer in this (unless it was Medicare who says no...but it's probably not Medicare in your case). Some payers will pay, some won't.
  41. L

    Picking level/elements of E/M

    the 1995 guidelines are pretty gray. The "2-4" and "5-7" guidelines are not so with certain payers. if you read the actual 1995 Guidelines, there are no such "numbers" given. Also keep in mind that you can also use the History and MDM to get a level 4, or 3. For an EPF exam using 95...
  42. L

    E/M amd scheduled procedures in hosp

    Probably not. What would the medical neccessity be? Is it just a pre-op visit? Even if there is no global period, that "procedure" still has some work value built in for the normal pre-procedure work/visit.
  43. L

    3 Year Rule When Billing E&M Visits

    Comepletely agree. Bypassing the claims system due to different tax ID's, abd getting your claim paid , does not make it right.
  44. L

    3 Year Rule When Billing E&M Visits

    Roxanne, per Medicare, same tax id & same specialty = same person. We have several clinics under the same tax id "umbrella". We do NOT charge a new patient when the patient switches clinics. I asked this very question to our MAC...
  45. L

    Partial Colectomy without anastamosis or end colostomy

    This is really a case by case issue, but I'm on track with CMartin. If they are simply "finishing up" a procedure the next day or so, I simply bill the complete procedure on one date of service. In your case, I agree with the 44160-52 and then the 44141-58 for the second procedure.(based in...
  46. L

    Billing OV Consult vs Hospital Consult

    If the service was provided in the office, then you should bill the office consult. I am not clear however, if your doc also went later to the hospital to see the patient again? Is that why you considering a hospital consult code?
  47. L

    E/M Visits prior to Screening Colon

    We don't bill these for any payer...and probably not a good idea to bill differently based on the payer.
  48. L

    mod 25

    it is not fraud to use a 25 on an office visit, and it have the same diagnosis as the procedure. What is fraud, is using the 25 just to get paid, when you know the office visit shouldn't be billed. You will have times when all you should bill is the procedure, and times when the visit is...
  49. L

    open appendectomy

    He was "thinking" it was trapped? Or it was trapped? If it was trapped, you could probably argue for medical neccessity, but may need to appeal if initial claim denies. Per the CPT book "the excision/repair of strangulated organs or structures....are reported by using the appropriate code for...
  50. L

    Attention issues

    Take a look at 799.51, that maybe what you want.
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