Fine needle aspiration biopsy Material is aspirated with a fine needle and the cells are examined cytologically. A 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. Use codes 10005 – 10012 for […]
Specialty Pages
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, […]
Intensive Behavioral Counseling for Cardiovascular Disease, HCPCS Code G0446
Medicare pays a primary care physician or other primary care practitioner in a primary care setting to annually provide one face-to-face behavioral counseling session for cardiovascular disease. Although CMS has developed a HCPCS code specifically for this service, many primary care clinicians perform this service as part of an E/M service or a wellness visit. […]
Coding Guide – Behavioral Health Services
The coding for psychiatric and psychotherapy services changed in 2013 and although that was years ago many psychiatrists, psychiatric nurse practitioners (NPs), and psychiatric physician assistants (PAs) are still adjusting to the change. This guide will answer questions about how to code for behavioral health services including: initial evaluations, re-evaluations, medication management, and psychotherapy.
Coding Guide – Preventive Medicine Services
Coding for preventive medicine services should be easy, but it’s not. It’s complicated by frequency issues, Medicare rules and the always difficult issue of when to bill a problem oriented E/M service on the same day. This guide includes coding and billing guidelines for preventive medicine services.
Behavioral Counseling for Obesity, HCPCS Code G0447
G0447 face-to-face behavioral counseling for obesity, 15 minutes G0473 Face-to-face behavioral counseling for obesity, group (2-10) 30 minutes Medicare pays for ongoing face-to-face behavioral counseling for patients with a body mass index (BMI) of ≥ 30, who are alert and able to participate in counseling. The service may be performed by a physician or non-physician […]
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.
Can you Screen for an Existing Condition? | Diagnosis Coding for Lab Services
Sometimes, the hardest thing about coding for preventive services isn’t the visit at all. It’s the labs. Patients come in for an annual physical and believe that all of the lab work done that day or in preparation for that day will be covered as part of their preventive service. And we know what that […]
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?
CPT® Code 99483: Cognitive Assessment and Care Plan Services
Developed in 2018, this service describes an in-depth assessment and development of care plan services for new or established patients who have signs of cognitive impairment. Notice that the use of this code requires an independent historian, stated right in the CPT description. Cognitive assessment checklist Definition of CPT® code 99483 99483: Assessment of and […]
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 […]
Pessary Billing and Coding
Coding for Pessary Services Primary care practices, gynecology and urology practices often prescribe and provide pessaries. A pessary is used to treat pelvic organ prolapse and for urinary incontinence. It provides support for the vaginal walls, uterus, bladder or rectum. A physician or non-physician practitioner (NPP) must first see the patient, take a history, examine […]
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. […]
Wound Care | CPT® Codes for Debridement
Health care organizations have started wound care clinics to care for patients with non-healing wounds and frequently use wound care debridement codes to report the services. The care of a post-op wound is done by the surgeon in the global period, and is not separately paid, unless it is on-going and the care for the […]
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 […]
Moderate or High MDM – General Surgery
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. Examples of Moderate MDM: Codes: Consult, 99244, Initial hospital 99222, Initial OBS 99219, 99235, ED 99284 Patient presents with a […]
Coding Guide – Global Surgery
This guide from CodingIntel explains surgery coding guidelines and the global period for procedures, and includes the contents of our original CPT® and HCPCS Modifier Guide.
Excision of Soft Tissue, Lipoma Removal
This chart is a quick reference for soft tissue excision. It includes anatomic location and size for subcutaneous and subfacial excisions.
Excision of Benign or Malignant Lesions
This article reviews codes and guidelines for excision of skin lesions. For more information about minor procedures, see additional resources at the bottom of this page. This article includes: CPT® Codes for Excision Excision of Benign Lesions Excision of Malignant Lesions Excision of Soft Tumors Reporting Excision of Multiple Lesions of the Same Size Coding […]
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