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July 4, 2025

Surgical procedures, modifiers, and the global package

CMS and CPT both define the components of the global surgical package to include certain pre-op, intra-op, and post-op services. Learn what is included in the single payment, what may be reported separately and how to do it.

 

Problematic Modifiers – 22, -52, -58, -78, -79 | Webinar

Recorded June 19th, 2025

Guest presenter Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O

This webinar will focus on selected CPT® modifiers that tend to be problematic for coders and claims processing. The instructor will focus on the application of modifier-22 and -52 including commonalities and differences as stated by the AMA as well as supportive citations from the Medicare Claims Processing Manual.

Can I Get Paid For…Removal of Sutures or Staples

For a code that reimburses at about $10, can you even remember how many times you’ve been asked that question? How do I bill for suture removal again? The answer to the second question is that there are three CPT® codes for removal of sutures or staples. Back to list

Commonly Performed Procedures in Primary Care

These reference sheets for minor procedures include common CPT® codes, descriptions, current work and non-facility RVUs, and global days for quick reference. The first chart includes codes 10060-11443, the second 11600-17111, and the third 20550-54056.

Modifier 25

Use of Modifier 25 may be applicable when an E/M service is provided on the same day as a procedure, a  preventive medicine service, or other medical service or procedure. Use this quick reference sheet to determine when to use modifier 25, and which code to append it to.

Coding Multiple Procedures | Examples with Modifiers

Biopsies and lesion destruction codes are often performed at the same patient visit. This leads to questions about bundling and modifiers. There are two steps to billing these correctly and avoiding denials: Check the total RVU values Check the NCCI edits. There is a step-by-step procedure for coding multiple procedures at the end of this […]

Reporting the Global Surgical Package | Webinar

Event date July 17, 2025

The global surgical package provides a single payment for services normally performed before, during and after a procedure. This webinar will review both CPT and CMS rules and explain what services are included in the payment and what services may be reported separately.

Lesion Destruction Tip Sheet

CPT® does not make it easy to locate codes for destruction of lesion(s). These codes are found in multiple chapters throughout the CPT® book, and are classified by a variety of factors (size, method of destruction, type (pre-malignant/malignant/benign), etc.) Accurate coding is essential to accurate payment. This tip sheet was created to help you quickly locate the correct CPT® code for lesion destruction.

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 […]

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 […]

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 […]

Coding for Destruction of Malignant Lesions

The primary factors in selecting a code for destruction of malignant lesions are: Size of lesion (not defect) Location Method is not a factor in code selection Per Principles of CPT® Coding: “The destruction of malignant lesions is reported with codes 17260—17286. Similar to the codes for excision of lesions, the correct code is chosen […]

CPT® Codes for Fine Needle Aspiration

Fine needle aspiration biopsy Material is aspirated with a fine needle and the cells are examined cytologically Core needle biopsy is performed with a larger bore needle to obtain a core sample Use code 10021 for FNA without imaging guidance, first lesion and 10004 for each additional lesions There are codes for FNA include imaging […]

Skin Biopsies

Correctly selecting and reporting skin biopsies requires an understanding of CPT® codes for skin biopsies There are codes for excision of benign and malignant lesions, and codes for shave procedures.  Those are coded based on the size of the excision and location There are specific biopsy codes in other chapters, for biopsy of ears, lips, […]

Coding Guide – Minor Surgical Procedures

This guide includes definitions of minor procedures used frequently in primary care and urgent care. And, even more important, instructions for billing the services. No minor procedure guide would be complete without a discussion of modifier 25. It is also the reference for CodingIntel’s minor procedures webinar which you can watch here.

What Does the Decision to Perform a Minor Procedure Really Mean?

This article is updated with CPT’s March 2023 document, “Reporting CPT Modifier 25.” (citation at the end of the article) The CPT article adds specificity to what is included in typical pre and post work, which will make it more difficult to report both a procedure and an E/M service for some encounters. According to […]

Selecting CPT® Rules for Excision of Skin Lesions

Many medical practices perform skin procedures.  A patient may see a dermatologist, a family physician or a surgeon when the time comes to find out, “What’s this thing growing on my arm?”  This article discusses excision of benign and malignant lesions. Shaves, biopsies, and destruction of lesions are covered in other articles. Per CPT, excision […]

Destruction of Benign or Pre-Malignant Lesions

Finding the right code for lesion destruction is not easy. The codes are distributed in the CPT® book in the integumentary, digestive, male genital system, female genital system, and eye and ocular systems. Some of the codes are selected by the method of destruction and some are not.  Some of the codes are selected based […]

Avoid These 4 Costly Errors When Coding Minor Surgical Procedures

Does your practice perform any minor or major procedures? If so, this post is for you! This post relates to the global package, and not to determining the risk of additional diagnostic testing or treatment in an E/M service. Primary care practices and urgent care centers should pay special attention to these issues and avoid […]

Billing for Multiple Surgical Procedures

When billing for multiple procedures on the same day, use this step by step procedure to determine if you should bill for more than one procedure, and if so, if you should use modifier 51 or modifier 59. It is critical to have access to National Correct Coding Initiative ((NCCI) edits in your software program.  […]

Modifier 57

Decision for Surgery.  An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. The payment for major surgery includes E/M services provided on the day of and the day before a major surgical procedure, unless it […]

Modifier 24

Understanding E/M modifiers is important for both revenue and compliance. Failing to apply the correct modifier reduces revenue. Applying the wrong modifier or using it when it is not accurate is a compliance issue and puts the practice at risk for payback and disclosures. For additional information, see the article on Global Surgical Package. Modifier […]

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IRE Inpatient Determinations: Case Studiesoding for Prolonged Services | Webinar

Exclusively for members, this case-study focused webinar describes important ICD-10-CM Guidelines that establish the rules for these decisions.

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Annual CPT® Changes Webinar

CodingIntel welcomes back Shannon McCall of HCPro for this review of changes that will go into effect January 1st, 2025. Exclusively for members.

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Compliance for Medical Practices

Exclusively for members, this two module concentration includes guidance for developing an audit workplan, and how to locate source citations for common healthcare compliance scenarios.

Join today!

IRE Inpatient Determinations: Case Studiesoding for Prolonged Services | Webinar

Exclusively for members, this case-study focused webinar describes important ICD-10-CM Guidelines that establish the rules for these decisions.

Join today!

Annual CPT® Changes Webinar

CodingIntel welcomes back Shannon McCall of HCPro for this review of changes that will go into effect January 1st, 2025. Exclusively for members.

Join now
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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

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