1. E

    Help With Dx Code for S/P C-Section, Now with Hemorrhage?

    What is the best diagnosis code to assign for a patient who is s/p c-section now with hemorrhage? She has already been dc'd home and presented elsewhere for the hemorrhage and was transferred back to hospital she delivered in. I looked at the post-procedural complications, but there is nothing...
  2. K

    Coding w/o a pathology

    Patient referred to our oncologist with a solitary pulmonary nodule, no pathology. The physician has entered a cancer diagnosis into the patient's EMR. She states that this is a clinical diagnosis based on her findings and patient history. I have advised her against this in the event that...
  3. M

    Billing for Telemedicine

    I have a question regarding billing for Telemedicine. My primary care health provider is looking at doing Telemedicine. We are looking at doing it for Maryland residents (as we are a Maryland practice) and I have already done some research into which insurance providers do allow billing for...
  4. H

    Office surgery vs otpt surgery

    Can a physician schedule a surgery in the office (place of service code 11) and take the patient into the ambulatory surgical center (place of service code 24) and bill only the physician portion with place of service code 11? Example: A physician schedules a YAG in the office. Physician takes...
  5. E

    Status Post C-Section - Now with Hemorrhage???

    What is the best diagnosis code to assign for a patient who is s/p c-section now with hemorrhage? She has already been dc'd home. I looked at the post-procedural complications, but there is nothing in this to specify patient was s/p delivery, c-section, etc. so I was't sure...... Any thoughts...
  6. M


    Hel with Orthopedic Surgery Coding Request 1. Right hand crush 2. Extensor pollicis longus tear 3. Extensor digitorum tear to the ring and small fingers 4. Extensor carpi ulnaris tear 5. Comminuted distal ulnar fracture 6. Distal radial ulnar joint disruption and dislocation 7. Perilunate...
  7. J

    Z86.79 - Duration of previous Diagnosis?

    Hello! Please, we're a little stumped on this one. A "personal history of" code explains a diagnosis that a. no longer exists and b. the patient is not getting any treatment for BUT c. could reoccur and therefore requires monitoring. Is there a rule on how much time has to pass before a...
  8. S

    Charge for paperwork

    A patient came in just to have paperwork filled out by the physician. Can we charge the patient for this? Thanks, Caroline
  9. A

    Modifier TD

    Does anyone use modifier TD for services performed during an RN only visit? For example, patient comes in for a B12 shot which was ordered by the provider. Patient brings in product, the only service to bill is the 96372. Do you add the TD modifier to indicate this was a nursing visit billed...
  10. aimeeread

    Elevated INR for patient NOT on anti-coagulation therapy

    How would you code elevated INR for a patient not on anti-coagulants? I've indexed "abnormal" and "elevated" both and can't come up with anything that I am happy with. R79.1 (abnormal coagulation profile) is about as close as I've come...but, there is no mention of the INR in the tabular notes...
  11. N

    establishing a patient

    how do you code an encounter when the patient came in to establish care. No problems are documented. Basically it a meet and greet thing..
  12. J

    Lipoma removal or more?

    I am not sure if I have this coded correctly. I have used 27047 for the lipoma removal, however I am not sure if there is more to this procedure than that. PREOPERATIVE DIAGNOSIS: Left inguinal mass. POSTOPERATIVE DIAGNOSIS: Left inguinal mass. OPERATION: Left inguinal exploration...
  13. D

    Coding of Rotator Cuff Tear

    If a patient presents with Shoulder pain and after exam the doc diagnoses the patient with a Rotator Cuff Tear but the patient did not sustain an injury and no prior shoulder surgery or pain, would this be billed with an M code or S code? I was thinking S code but there I am not able to provide...
  14. C

    Out patient hospital coding assistance

    If a patient is seen by the provider as an op in bed, due to vomiting in pregnancy can we bill an e&m visit from the 99212-99214 level... She is getting treated with us for her ob. Im confused as it does not state inpatient or observation status.
  15. B

    Attempted closed reduction of incarcerated hernia.

    I'm seeking coding advice. Any help would be greatly appreciated. The patient was seen in the office for a incarcerated right inguinal hernia. The physician then attempted to manually manipulate the hernia. Below I have included the description of procedure. "With patient under general...
  16. K


    Hi there. I need some help with this OP report. Doc wants to bill 38500 for a deep lymph node excision of cheek. Is there another option? I read that all facial lymph node excisions are superficial, but this one goes down to muscle. I did question him about using CPT 21013, excision soft...
  17. D

    Face to face time with e/m coding

    Can someone tell me if face to face time has to be consecutive or if the dr can see the patient, send them to audiology for a test,and then see the patient again to review the results of the audiology test? Can she bill for the time before and after seeing the audiologist?
  18. C

    Interphalangeal Joint Reduction

    Patient had interphalangeal dislocation of right middle and ring finger and both were reduced. Would I report 26770 twice with 76 on the second or do I just link both to 26770? Thanks
  19. D

    26720 fracture coding help

    patient has two broken fingers on the same hand would I bill 26720 by itself or 26720 with 2 units
  20. J

    Modifier ET

    Hello everyone. Currently our office is out-of-network with UPMC. Our physician is plastics/hand specialist and is on-call at our local hospital. He often gets called for UPMC patients. Recently, he has found modifier ET and wants to affix it to all his codes because he thinks he should be...
  21. G

    Anemia sequencing

    In what order would dx be sequenced for a patient w/malignancy and anemia. How should should documentation read?
  22. S

    Bilateral inguinal hernia/one side repaired - I have an op report that has Pre and Po

    I have an op report that has Pre and Postoperative diagnosis of bilateral inguinal hernia, but they only repaired the Lt side because the right was not causing patient issues and the patient did not want it done (had to be done open). For the dx would I code it as bilateral or unilateral? Thanks!!!
  23. L

    Hysteroscopy D&C

    Patient had a missed Abortion and we performed 59820 on 11/9/15. Patient had several episodes of heavy bleeding following this. We then performed a Hysteroscopy D&C would I use 58558 with modifier 78 or do I use the 59160?
  24. C

    Provider signature rules

    Is a provider required to view and sign patient records received form another provider outside of the practice that was simply sent to us as an FYI and is added to our medical record on the patient? Is there any legal liability in the provider being aware of these external records and/or...
  25. T

    "screening labs" help please

    Our patients are getting bills for labs done as part of their physicals. Mostly for Vitamin D. How are you suppose to code for labs other than the Z00.00. Especially if the patient doesn't end up having any of the problems you are testing for. These tests are expensive, how do you know if...
  26. M

    New Patient Who Was Once Established

    If we have a patient return to office that hasn't been seen in 3 years- we bill them as a new patient. Does this mean they also have to complete all new patient paperwork? Or can we obtain all information verbally? Such as, insurance, address, phone number, past medical history, surgeries and so...
  27. M

    Does new insurance mean new patient??

    I was told by a provider that when a patient obtains a new insurance, they are billed as a new patient (regardless of when they were last seen). The provider agrees that if someone hasn't been seen for three full years that they are a new patient. However, they have also been told that even if...
  28. A

    15271-plea for help!

    We recently started a Wound clinic in an office setting at the hospital. I'm billing for the professional services. The following was documented in the medical record and my doc states to bill 15271. Does this qualify? He is doing a lot of return Epifix applications when patients are seen back...
  29. L

    SI Region Injection

    Hello, The patient was being seen for left knee and indicated that he was having a lot of pain into the left leg from the inguinal region into the SI joint and down the left leg and into the thigh. I have a report that reads that the Patient had an injection into the left SI region, 80 mg of...
  30. Colliemom

    Remicaid infusions

    Hi guys, I was hoping someone could help us. A patient came in for a Remicaid infusion. The drug was mixed, and the infusion started. During the infusion the patient had a reaction and the infusion had to be discontinued. Because the drug was already mixed, the remaining infusion had to be...
  31. S

    Incomplete EGD-Opinions please!

    Opinions please! :) I have a patient who was scheduled for an EGD and colonoscopy. The EGD was unable to be completed due to the patient having a very small mouth and torticollis. They were unable to even insert the mouth guard in the patient's mouth. The patient was already sedated, but was...
  32. T

    New to Outpatient Hospital Coding

    Scenario: A patient is registered in the hospital as outpatient and the physician sees the patient. Do they bill under 99201-99205 or 99211-99215? New versus established rules would apply in this case. Any help is appreciated.
  33. C

    Aneurysm Coding

    Hello again, I think I am looking too much into this report. Any input would be appreciated. PREOPERATIVE DIAGNOSES: Aortic dissection with a descending thoracic aortic pseudoclaudication, malperfusion to the mesenteric vessels and lower extremities. POSTOPERATIVE DIAGNOSES: Aortic...
  34. A

    Wiki Status post epidural lumbar injection

    Im trying to find the ICD 10 code is pertinent because the patient presents to ED with headaches 1 week after the injection...any suggestions?
  35. M

    Coding Question - Chondromalacia

    1. LT Knee Chondromalacia of patella type 2 to 3 2. Extensive Synovitits 3. Posterior third medical meniscal with type 3 to 4 chondromalacia on the medical femoral condyle 4. Loose Body 1. Complete Synovectomy of the superior patella pouch, inferior patella pouch, medial gutters and lateral...
  36. E

    medicare auditing for payor

    When coding charts for Medicare audits: If a pcp is coding cancer as current and the specialist is saying the patient is in remission can we change the pcp code to hx of cancer?
  37. C

    Spontaneous Abortion code

    patient was admitted for vaginal bleeding at 19 weeks, was diagnosed with fetal demise patient had cytotec and later that day had an spontaneous MAB, according to guidelines you can't billed 59820 as is a surgical procedure. What CPT code will be the best option at this time?
  38. C

    coding currently undergoing chemotherapy I-10

    Hello, Is there a way to document that a patient is currently undergoing chemo. for lung CA Coding ER and patient has a wound infection not related to chemo, but would like to document chemotherapy as an associated condition. Thanks!
  39. A

    CPC-A with Masters Degree in Health Systems Admin.

    Could not get the attachment to work, please see unformatted resume below. Thank you. Austin Wentworth, M.S., CPC-A Liverpool, NY 13088 SUMMARY Skilled professional with exceptional team communication and task management ability. Demonstrated success on many levels...
  40. J

    Lengthy Peripheral study-need help!

    OK, would someone please be willing to read this and let me know about codes? I have: 93454.26 36221 92928.RC 92978.26.RC 75710.26 I'm stuck on the rest. Could the 35475/75962.26 be used for PTA of radial artery? Any catheter placement code I may be missing? Uggh, this one was a doozy for me...
  41. G

    More "A" "D" questions regarding MRI studies

    I need some other opinions on utilizing the 7th character if the patient comes to our facility for an MRI SCAN of a body part do to a previous fracture. Patient was initially seen in the ER and had a CT Scan. Now they need an MRI SCAN. What is the appropriate coding from my standpoint. All...
  42. ljones88

    Patient with history of nasopharyngeal cancer comes for laryngoscopy

    Hi, I searched the threads and couldn't find a thread related to my issue. An established patient with a history of nasopharyngeal cancer is seen in the office for a laryngoscopy. Physician also documents an E/M and removed impacted cerumen from the ears. Patient completed chemo and radiation...
  43. K

    new vs established patient-organization aquires

    If an organization aquires a practice and all providers remain at the practice but the tax ID # changes. Should all the first visits for their exisisting patients be billed as a new patient visits?
  44. C

    Inpatient Consult

    If a patient was in the hospital and a consult was requested from a provider and then a month later that same provider was called in to do another consult for a new problem and the patient had been in the hospital the whole time, would you bill a new consult or subsequent visit?
  45. S

    OB Coding

    I am currently trying to find an ICD-10 code for discontinued medication due to patient being pregnant. The medication is Lithium. Any help?
  46. N

    2 providers 1 patient same day DIFF.SPECIALTIES

    What modifier can I use for denied claims when 2 providers see the same patient on the same day? Long term care setting. A NP sees pt then the physiatry doctor sees the patient. Same practice but one provider is a specialist and the other is a physicians assistant or NP... we get denials but I...
  47. C

    HBIG Vaccine coding help please

    I need help on how to code for the HBIG Vaccine for a patient who had a needle stick from a contaminated needle from a patient with HBV. The patient received the HBIG Vaccine and I'm not sure how to code the CPT portion? Since the cost is about 15x higher then the regular vaccine I needed to...
  48. M

    New Patients for Pain Management

    A new patient is referred for evaluation and treatment, and based on imaging and medical documentation from the referring the provider performs an epidural steroid injection. Is it appropriate to bill a new patient E&M with modifier -25 in addition to the procedure to establish patient care or...
  49. A

    Loss of Domain

    In ICD-9-CM Vol 1, when the surgeon documented loss of domain in an abdominal surgical wound, we were advised to use ICD-9-CM code 879.3 for Open wound of abd wall, anterior, complicated. See "Expose the Layers of Abdominal Wall Reconstruction" In Coding Edge June 25, 2010 By John F. Bishop...
  50. V

    E&M Coding: New vs Established

    Hello Friends! I have recently been asked for some clarification on how we do E&M coding for an inpatient setting. We are an infectious disease specialty clinic and are called in for consultations. Sometimes it is a patient that we have already seen in our clinic, and the consult is for the...