Everyday Coding Q&A

When meeting with coders and clinicians, the same issues and concerns arise year after year. We've translated those into a searchable Everyday Coding Q&A.

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) D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin Answer: The answer is b! Use an unspecified code when a specific diagnosis code is not known at the […]

Are Start and Stop Times Required for Non Face-to-Face Prolonged Care Services?

Question: Regarding non face-to-face prolonged care, does Medicare require start and stop times, they way they do for prolonged face-to-face care? As long as the provider documents the total time spent reviewing old records is sufficient to bill this service, am I correct? (Codes 99358, 99359) Note, beginning 1/1/2023 these codes have an invalid status indicator […]

Teaching Physician Rules | Bedside Procedures

Question: Can an attending bill for a bedside procedure that a resident did without the attending being present? If so, is this billed at 85% like a PA or NP? If a PA or NP is overseeing a bedside procedure that a resident is preforming how is this billed (no attending is present at the […]

Scoring MDM in an E/M Note

ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023. This article does not apply to services performed after 1-1-2023. Question: I have a question about scoring MDM in an E/M note. One of our coders thinks that if there […]

Can We Bill for IUD Removal and Insertion on the Same Day?

Question: Can I bill 58301 for IUD removal and bill 58300 for IUD insertion on the same day, if the provider removes and then inserts another IUD? And, can we bill an E/M with it? Answer: Yes, there is no CCI edit for those two codes. In years past, I heard that some payers denied […]

Diagnosis Coding for Tick Bites

Question: Why is it so hard to have correct diagnosis coding for tick bites? And, how is it coded? Answer: The search function in electronic health records leads clinicians astray. And, diagnosis coding for tick bites requires two diagnosis codes, because it is an injury. It requires a code from the injury chapter in the […]

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