“A colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine to an anastomosis.”[1] In 2015, CPT® revised some definitions related to colonoscopy and added a decision tree to help practices select the correct CPT® code and the correct […]
Overview of Diagnosis Coding for Behavioral Health Services
Match diagnoses on the claim form to those listed in assessment The diagnosis codes on the claim form should match those in the note. If the assessment says “stable on medications” or “doing well,” it isn’t clear how many conditions were managed and treated In the assessment, list conditions managed, their status, and treated Note […]
Medication Management and Psychotherapy Reference Sheet
This quick reference sheet illustrates the coding and documentation requirements for medication management services with, or without psychotherapy.
Psychiatric Diagnostic Evaluation
There are two codes for psychiatric diagnostic evaluation. 90791 Psychiatric diagnostic evaluation 90792 Psychiatric diagnostic evaluation with medical services 90791 is used by psychologists, social workers and other licensed behavioral health professional and 90792 is used by psychiatrists and psychiatric nurse practitioners and physician assistants, because it includes medical services. Here is how CPT® defines […]
Psychotherapy Codes
Individual psychotherapy codes are time based codes. One set may be reported as a stand alone service, and another during the same visit as medication management. They follow the CPT®; time rule: use the code when the mid-point in the defined time is met. The CPT® book itself lists the time thresholds at the start […]
Psychotherapy for Patients in Crisis
Page down for 2024 HCPCS codes for G0017, G0018 90839 is the code for psychotherapy for crisis; first 60 minutes. 90840 is an add-on code for each additional 30 minutes of time spent with a patient who is in crisis. These codes do not have CPT® limitations on place of service. They would typically be […]
Interactive Complexity | CPT® 90785
Code 90785 is an add-on code for interactive complexity and may be added on to the diagnostic psychiatric evaluation (90791, 90792), to psychotherapy services (90833—90838), and to group psychotherapy (90853). It may not be reported with an E/M service, if no psychotherapy is performed on that day, or with psychotherapy for crisis, 90839, 90840. Code […]
Everyday Dermatology Coding
Everyday Dermatology Coding is a 52 page guide to coding dermatology services.
Screening for Skin Cancer
Dermatologists frequently see patients for skin checks, to examine their skin for signs of pre-malignant or malignant lesions. Some of these patients have a personal history of malignant skin neoplasms, and some do not. The appointments may be scheduled annually or bi-annually. Will insurance pay for screening for skin cancer? Medicare and private insurances are […]
Diagnosis Coding for Dermatology
Diagnosis notes for dermatology Be sure to match the diagnosis to the procedure. For example, For skin tag removal, use skin tag For treatment of warts, use warts For excision of malignant lesions, use a malignant lesion code Describe conditions in the physical exam Only use diagnosis of “inflamed” seborrheic keratosis if the exam describes […]
Coding for Breast Procedures: Biopsy, Localization Devices, and Surgery
From biopsy to localization device to mastectomy, coding for breast procedures can be challenging. This article summarizes the rules related to these services. Fine needle aspiration of a breast mass, or aspiration of a cyst Fine needle aspiration (FNA) of a breast mass is reported with codes 10021—10012. CPT® developed new codes for FNA in 2019. […]
Overview of Medicare Telehealth Services
Please see the Telemedicine article for the rules and guidelines for use during the COVID-19 public health emergency. Medicare covers some services performed via real-time audio and video between a patient in an underserved area and a physician or other practitioner who is not in the same place as the patient. Requirements for Medicare telehealth […]
Coding Skin Procedures in Dermatology, Family Practice and Urgent Care | Webinar
Recorded February 21, 2019
This webinar will tell coders and practitioners how to document and code biopsies, destruction of benign and malignant lesions, and repairs. It includes specific examples of how to bill for multiple procedures with the correct modifiers, and when to use modifier -51, -59 and -58.
Repair (closure) CPT® 12001–13160–2020 update
Laceration or wound repair codes are reported based on the type of repair (simple, intermediate, complex), the anatomic location, and the length The length of multiple lacerations of the same type and defined as the same anatomic location are summed and reported with a single CPT code. For multiple lacerations of either different types or […]
Describe the Exam | E/M Services for Dermatology
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. What do you need to document for the exam? Although exam is not a key component in 2021 for codes […]
Coding for Mohs Micrographic Surgery
Mohs surgery is performed to remove complex or ill-defined skin cancer, and the procedure includes both the surgery and histopathologic examination. Both capacities are required in order to bill for these codes, and neither part may be delegated to another individual. Let’s look at the specific guidelines for coding for Mohs Micrographic Surgery: According to […]
Other Dermatologic Procedures
This aricle reviews the codes and guidelines for these dermatologic procedures; Intralesional injections, photodynamic therapy, phototherapy, and laser treatments. Intralesional injections Intralesional injections deliver a medication directly into a specific skin lesion, allowing the medication to be delivered over a period of time. Corticosteroids are common examples. Report either code 11900 for up to 7 […]
Modifier 51 or 59? How to Know Which to Bill?
Modifier 51 and 59 are both used on second and subsequent surgical procedures, when performed on the day of a primary procedure See also Modifier 59 quick reference sheet There are two modifiers commonly used in surgical specialties when billing two or more procedures at the same encounter. Appending the correct modifier increases the likelihood […]
Shaving of Epidermal or Dermal Lesions
The chart below includes CPT® codes, and descriptions for shaving epidermal and dermal lesions. After the chart, there are important key points to keep in mind when using these codes. Code Description 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less 11301 lesion diameter […]
Quick Coding Reference Sheet – Hospitalists
This quick coding reference sheet is a must have when coding E/M services for hospitalists. It covers consults, initial and subsequent hospital visits, and observation.
Quick Coding Reference Sheet – Dermatology
This dermatology specific E/M reference sheet includes 1997 single specialty skin exam and medical decision making examples relevant to your specialty. A must have reference for physicians and staff coding for dermatology services!
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