Question: What diagnosis code should you use when sending a biopsy to pathology? a) D48.5 Neoplasm of uncertain behavior of skin, or b) D49.2 … [Read more...]
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.
Incident to and change to medications
Question: A CodingIntel member writes: "I am getting mixed information about incident-to and I was wondering if you could weigh in? If a NPP … [Read more...]
Exam and time in a visit | Documentation requirements in E/M services
Question: For an established patient, if I don’t document a physical exam, am I required to say that the visit was a counseling visit and document … [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...]
Critical Care Services Rule | Two physicians billing for same time period
Question: Where does it say in CPT® that two physicians can’t bill for the same period of time when performing critical care? Answer: It … [Read more...]
Are start and stop times required for non face-to-face 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? … [Read more...]
Are subsequent hospital or office visits prior to surgery billable?
Question: Are the surgeon’s subsequent hospital visits or office visits between their original consult and the final visit prior to surgery … [Read more...]
Coding for biopsy | Should we wait for a pathology report?
Question: Should we always wait for the pathology report before submitting a code for a biopsy? Answer: Sometimes. Wait for the pathology … [Read more...]
Age and wellness visits | Eligibility for Welcome to Medicare
Question: Does the patient need to be 65 years old in order to bill the Welcome to Medicare Visit? Answer: No, there is no age restriction … [Read more...]
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 … [Read more...]
Can two practices split the post-op office care of a patient?
Question: Can two practices split the post-op office care of a patient? Answer: No. Although the operative and post-operative portions of the … [Read more...]
Scoring MDM in an E/M Note
Question: I have a question about scoring MDM in an E/M note. One of our coders thinks that if there is a new problem with labs ordered (new … [Read more...]
Teaching Physician and Resident Specialty | Medicare Teaching Physician Rules
Question: Can a teaching physician from one specialty supervise a resident in a different specialty. Answer: Although CMS updated the rules … [Read more...]
Prolonged services and nursing home visits
Question: Prolonged Services and nursing home visits. I'm getting a "Code 99358 is a column 2 code for 99309, these codes cannot be billed … [Read more...]
Wound Care CPT® Codes 11042 and 29580
Wound care CPT® Codes 11042 and 29580 Question: Our wound care physician billed for debriding a wound on the right foot and applied an Unna boot … [Read more...]
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? … [Read more...]
Determining new patient vs. established patient | CPT® Rules
Question: A physician wrote: “We have a cosmetic treatment center that is separate from our surgical clinic. I have seen a patient in the cosmetic … [Read more...]
Reporting Excision of Multiple Lesions of the Same Size
Question: The doctor I work with excised two benign lesions from a patient’s arm, of the same length. Do I add them together and report one code? … [Read more...]
Diagnosis Coding for Tick Bites
Question: Why is it so hard to code for a tick bite? And, how is it coded? Answer: The provider searches for the word “tick” and in many … [Read more...]
Psychotherapy Documentation Guidelines | Time
Question: Is it okay to use the time description in the order as the documentation of the psychotherapy time? The therapist selects 90832, … [Read more...]