Everyday Coding Q&A

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You have questions, we have answers. We will be taking the questions we receive from you and posting answers on a monthly basis. Do you have a question whose answer would benefit fellow physicians, coders, or staff as well as yourself? Send it to info@codingintel.com.

Should we begin using the new CPT modifier -93

Question: Should we begin using the new CPT® modifier -93? Answer: I recommend a wait and see approach. Here’s the definition from the AMA, … [Read more...]

Can we bill a new patient visit for preventive and E/M services on the same day?

See our on-demand webinar, Preventive medicine and Medicare wellness visits with an E/M. Question: Our physician saw a patient and did a … [Read more...]

Does HCPCS code G0444 require a full 15 minutes?

Question Does HCPCS code G0444 require a full 15 minutes, or can you use it if 8 minutes are documented? Answer The reason for this question … [Read more...]

Coding for laceration repair, two visits on the same day

Question In our urgent care center, our physician treated a child for a lip laceration in the morning, closing it with dermabond. Later that … [Read more...]

FAQ: Scoring the elements in the new E/M guidelines for 2021

Scoring elements can be challenging with the new E/M guidelines for 2021. This article is updated based on the 5/25/2021 AMA webinar, given by … [Read more...]

Social determinants of health

Question: I see that the new E/M guidelines for codes 99202—99215 include social determinants of health, as moderate complexity. What is a social … [Read more...]

Why and when to use Modifier CS

Question: Why and when should we use modifier CS? Answer: Use modifier CS on visits related to testing for COVID-19. Modifier CS: cost … [Read more...]

APRN and PA students and medical record documentation

Question We have students from a nurse practitioner program rotate through our practice. Can we use their notes the same way as medical student … [Read more...]

Can we give a flu shot if the doctor isn’t in the office?

Question: Do we need to have a physician in the office when our clinical staff gives flu shots? Answer: No. CMS allows flu shots to be given … [Read more...]

Non-physician practitioners in nursing facilities

Find additional information about nursing facility services in Betsy's signature resource Everyday Coding. Question: Can a physician assistant … [Read more...]

Can we bill an E/M service with a scheduled endoscopy?

Question: Can we charge an E/M service when we do a scheduled endoscopy to account for the cost of nursing staff, supplies, pre- and post- care of … [Read more...]

Re-admission to nursing facility

Question: If a patient is re-admitted to a nursing facility after an inpatient stay, should we bill an initial nursing facility visit or a … [Read more...]

Counting conditions in the HPI and assessment

Question: This question pertains to the 1995/1997 Guidelines, and not to the revised office/outpatient codes 99202--99215 in 2021. When … [Read more...]

Transferring a sick baby to another hospital

Question: Our pediatric group practices in a community hospital, without an NICU. My pediatrician was called to attend a delivery of a newborn who … [Read more...]

Drug therapy requiring intensive monitoring for toxicity

Question: When auditing MDM, is there a list of drugs that are considered “drug therapy requiring intensive monitoring for … [Read more...]

What is an interval history?

Question: What does it mean when it says a code requires an “interval” history? This question related to the 1995/1997 Documentation … [Read more...]

Initial hospital service codes and established patients

Question: We are having a disagreement in our coding department. Our cardiologist sees an inpatient at the hospital, but it’s a patient she knows … [Read more...]

ROS requirements for preventive services OB/GYN

Question: What are the review of system requirements when an annual physical (99381-99387, 99391-99397) is performed/billed by an OBGYN … [Read more...]

Diagnosis coding for biopsy sent for pathology

Question: What diagnosis code should you use when sending a skin biopsy to pathology? a) D48.5 Neoplasm of uncertain behavior of skin, or b) … [Read more...]

Billing inpatient consultation for Medicare patients | Initial visit or subsequent

Question: What should a consulting physician bill when seeing a hospitalized Medicare patient? An initial hospital service or a subsequent hospital … [Read more...]