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    Question Modifier 25

    Also of note: modifier 25 is for when a separately identifiable E/M is done same day as a minor procedure (0 or 10 day global), but modifier 57 is for an E/M on same day or day before a major procedure (90 day global). Use of the wrong modifier will result in a bundling denial.
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    Question Fracture care - Distal Radius/Ulna

    According to this article, it may depend on the payer. However, I play it safe and assume everyone goes by Medicare rules on this. https://www.karenzupko.com/multiple-fractures-one-code-multiple/
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    Question polydactyly

    I'm trying to make sense of this. 79 modifier would indicate it is in global of another procedure? You shouldn't need any digit/laterality modifier for 11200. Not sure what you mean by level 11 modifier? If it is not in global of another procedure and patient had E/M with first provider and...
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    New patient= New diagnoses points?

    If the patient is truly a new patient (not been seen by any of the providers within that billing group, then it is considered a new problem. The audit tool I have specifically states 'New problem (to examiner)'. However, if it is a self-limited or minor problem it doesn't distinguish between...
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    25332 vs 25447

    I would actually go with 25447; I've seen this surgery multiple times. I haven't seen one for 25332 before so I had to look that one up. Per the coder's desk reference, 25332 has to do with the carpal and radius/ulnar joints but 25447 has to do with the metacarpal and carpal joints.
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    Question Missed Abortion coding D & E

    This isn't my specialty, but I'm willing to offer a couple of thoughts on it since no one else has. Although you might consider posting it in the OBGYN area of the forums to find the experts. -Was sepsis due to retained products mentioned? If so that is a different CPT. -Consider if it was...
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    Question 20910 vs 21230

    Hi Walker, -20910 is for the harvest of the graft alone. If you were doing a procedure that didn't bundle the graft harvest, you could bill 20910 with it. -21230 includes graft harvest as well as the repair/reconstruction with placement of the harvested graft. Since 21230 states 'includes...
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    Documentation 28193 depth

    The dermis is actually above the subcutaneous. 28190 is subcutaneous, 28192 is deeper than subcutaneous tissues. The Coder's Desk Reference is a wonderful guide if you are able to get one. It advises that 28193 may include incision, repair of any torn tendons, nerves or blood supply. Technically...
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    Psychology/Psychiatry

    96138 bundles to 96136, but you can add a 59 modifier to 96138 as long as the provider and technician performed different testing. If it still denies, try appealing.
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    Ribs

    You would have to review each payer's policy on this to see if this applies to your patient, but I found nearly identical responses for Aetna and Amerigroup that explain the conditions of when it is considered medically necessary. This also explains their reasoning for when it is not...
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    Need help with this one please

    I'd look at 27745 for the cementation and fixation. The excision and biopsy will bundle into this so they cannot be billed. I couldn't find a code for the cryotherapy, but perhaps someone else is familiar with this?
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    Question New Visit vs. Established visit after EKG

    You should be able to still bill a new patient visit. I was able to find this information on Noridian: Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or...
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    Question appeal decisions

    Hopefully an ABN was signed? You might try appealing based on a change in medical condition- see the attached from a DME webinar: http://aapcperfect.s3.amazonaws.com/e7fe2e86-ee05-475b-ac2c-bdc28fea95c1/13d0939d-0a57-44a9-afea-3e1d6b349bb7/177474d8-73f6-4cb4-88b7-77fda2d11155.pdf
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    Question billing self pay in optometry

    I agree there should only be one fee schedule. I'd advise against creating alternate pricing. However I believe most systems allow for a discount function to be applied, so perhaps you can set this up?
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    Fracture Treatment - Reapply Cast

    Casts applied after the initial one can be billed. You will need to append a 58 modifier to indicate a staged procedure.
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    PT billing

    If the documentation reflects separate services with no overlap of time, both should be billable.
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    Question Walking boot for ankle sprain denied as "routine"?

    I haven't seen that denial for a boot before, but I have a few questions to maybe narrow the issue down: -What HCPCS did you bill? -Was it billed with home as POS? -Was there any service other than the E/M billed? -Have you reviewed their DME policy...
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    Arthroscopic Tarsal tunnel release

    Unfortunately there is not. You'll just have to go with unlisted and use 28035 as the comparison code.
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    UHC MEDICARE REJECTION

    Was W55.81XA listed as the primary diagnosis? If so, then I'd say that is your issue. An external cause code should never be listed as the first diagnosis.
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    Whether we need to add 52 modifier for 10120 ?

    I'd take a look at this thread https://www.aapc.com/discuss/threads/foreign-body-removal.3821/ If a foreign body was removed without an incision, it should be included in an E&M. However that is not the case here. I think the consensus of the thread is 10120-52.
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    Nail Debridement and Diabetes

    I believe you mean 11720, G0246 and G0247? G0247 includes the nail debridement in a diabetic patient with neuropathy and loss of sensation, so you would not also bill 11720. G0247 requires a primary code of either G0245 or G0246; whichever is appropriate based on documentation. Definitely bill...
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    Question How do you code an Evans procedure - cuboid osteotomy?

    I think you're on the right track. I agree that 28260 and 28300 do not appear to be appropriate for what was done. It seems to be closest to either 28304 or 28305. I feel like it was more work than 28304 because of the insertion of the wedge, but less than 28305 because the graft was not...
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    Question Billing for Shave biopsy 11102 and 87207-26 -or- 88305-26 ?

    Collection of the specimen would be included in 11102, as stated in the biopsy guidelines of the CPT manual. I don't believe your provider can bill the pathology codes unless he has met the following: A separate, signed interpretation and report similar to that which would be prepared by a...
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    ORIF WITH PERCUTANEOUS PINNING

    If you were to look up the diagnosis under dislocation, it states underneath in the index 'with fracture- see Fracture'. So I would just code it as fracture. With that said, you can then rule out the dislocation CPTs. Whether you choose 26615 or 26608 is dependent upon what was done.
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    fracture care

    We need more information to be able to answer this. Was the provider that saw the patient in the ER in the same group as the in-office provider? Did the first provider bill fracture care? If they are separate groups such as ER physician and Ortho physician, I think it is likely that the...
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    cpt 14041

    14040 is the more comprehensive code. 14040 includes excision of the lesion (11400-11446). So unless the excision of the lesion is unrelated to the tissue transfer, you would not bill both.
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    right index/finger/middle finger/ring finger debridement

    I would just code the mucous cyst excision on this and consider the debridement to be part of the procedure. I'd look at 26160.
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    Percutaneous surgery and arthrocentesis

    What are you trying to bill with the 27306? Can you post a redacted note?
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    ED Consult with Closed Treatment

    Was manipulation done? If it was then I'd bill for the closed treatment with the E/M and 57 modifier for 3/27/19. Then bill the surgery on 4/8/19 with 58 modifier. If he is just evaluating it and then scheduling future surgery I'd just bill the E/M for 3/27/19 and wait to bill the fracture...
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    Coventry and 20611 denials

    I was able to reach Coventry and they are denying incorrectly. They said it denied due to LCD A56157, but that only is for knee viscosupplementation injections. This has been denying on claims with steroid injections of any of the major joints, so we will appeal further.
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    Coventry and 20611 denials

    They have generally been billed with a pain code primary when billing 20610 or 20611 with J3301, such as M25.511 followed by the condition. We haven't billed with a G89 code, but this has never been an issue with any payer previously. It is worth a shot. Thanks!
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    Coventry and 20611 denials

    Has anyone else had issues with Coventry lately denying 20611 as not medically necessary per LCD? The only LCD I can find is for injections of the knee with hyaluronan. However, the ones that are denying are not being injected with hyaluronan and may be in any of the major joints, not just...
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    modifier needed for 73564?

    If you didn't bill it with a laterality modifier (RT/LT/50), that is most likely what they are asking for. If you did bill it with a laterality modifier already, then perhaps review to see if there were other x-rays it could bundle to or if a 26/TC is appropriate.
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    Elaine D

    These two codes bundle, but since they are for separate sides you should be able to bill both. I would add an XS modifier to 69424.
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    HELP! femoral fracture coding advice needed

    Honestly I feel like replacing the rod in the upper femur is incidental to the newest fracture so I would not bill for that. I would try adding a 22 modifier to 27511-79 to be compensated for the extra work.
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    trephination calcific tendonitis

    We debated this as well. The work done seems more extensive than 20610, but 23000 is for open procedure so that didn't seem appropriate either. We settled on an unlisted code with 23000 or 27306 as the comparison.
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    Interosseous ligament stabilization for a Essex-Lopresti injury

    You might look at 25320 to see if that is a good code for the repair. However, that does bundle to 25337 so you could only bill 25337.
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    11042 denying

    If it has been denying as not medically necessary, that is not likely due to a modifier. Have you reviewed the LCD to make sure the diagnosis you have linked to it is covered and that it fits any other requirements outlined in the LCD?
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    Modifier for Dermatology Excisions and Repairs being billed together

    The modifiers should not be interchangeable. If the two procedures bundle, determine if they were done for the same site; in this case you would not bill both charges. If the procedures bundle but are at different sites you should be able to append a modifier (59 or XS) to indicate why they are...
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    'Qualifying' Appeal

    I haven't seen this, but I have a few thoughts... -I assume you are trying to appeal a denial, not a rejection, correct? Some billers try to appeal a rejection but you cannot since it was not accepted for processing in the first place. -Have you verified the payer's requirements to submit an...
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    Transfer care with in same Ortho practice

    I was researching a similar issue recently. I did see where it was suggested that some practices may have an internal agreement to split up fracture care payment received from insurance, so no change in billing. The only other thing I can think of is to request a refund on the original billing...
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    PT/OT units

    Our physical and occupational therapists do their own coding, but I review denials. Most of the information I can find limits the number of units by the total time. They have been billing any services performed for at least 8 minutes. So for example they did 3 different services for 8 minutes...
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    Global Period ASC

    If the second surgery is on a different eye it is considered unrelated to the first eye surgery, so you should be able to add a 79 modifier to the second surgery.
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    Hand coders please do me a favor, tell me which codes are proper to submit please

    Can you please post an op report? Just from a quick glance, 20660 and 76000 seem out of place and 26445 would bundle to 26433 if it is the same tendon.
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    29871 or 29877

    I only see 29871. Even if 29877 or 27570 had been performed (which do not see), they would still bundle to 29871. They removed some hypertrophic synovium, but 29875 would also bundle to 29871.
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    Modifer 58 for asst surgeon

    Generally assistant surgeon claims should not need a global modifier and may deny if you try to add one because the payer edits do not like the two modifiers together. On rare occasion I'll get an assistant's claim that has denied for global, but normally you would not need a global modifier on...
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    Modifier 52&53

    Modifier 52 is for reduced services, so it mostly fits what is done for a procedure, but not completely so the payment should be reduced. For example, 27487 is revision of a total knee arthroplasty. If my provider only replaced the femoral component and the poly liner but not the tibial...
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    Injections and E/M

    This can be a tricky call sometimes. If this is the first injection, you can bill both the E/M and injection. If this is a repeat injection with nothing else evaluated and no change in plan of care, I'd bill just the injection. Sometimes my providers will document the patient has worsening pain...
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    Foreign Body Removal of Distal Fibula

    Is this a current injury so you could code S91.022A laceration w/ foreign body or S91.042A for puncture wound w/ foreign body? Also, was the foreign body removed from the bone itself? I'd recommend posting the documentation to see if there is a more appropriate code, but 27610 would mean going...
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    tenotomy

    It depends on what body area it is performed. In some areas there are codes for a percutaneous tenotomy; if there is a code for it I'd use that. i.e. 24357, 27000, 27306 I would not suggest using open tenotomy codes- I have issues with my provider trying to use that sometimes. If there is no...
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