Question: Are the surgeon’s subsequent hospital visits or office visits between their original consult and the final visit prior to surgery … [Read more...]
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.
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: This is almost a trick question. … [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
This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202--99215 in 2021. Question: I have a … [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...]
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 have correct diagnosis coding for tick bites? And, how is it coded? Answer: The search function in electronic … [Read more...]
Documenting time for moderate sedation of 15 minutes
Question: When my doctor personally performs moderate sedation of 15 minutes, does he/she need to document the time in the … [Read more...]