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Reader Question: Ask Physicians How to Count ‘Supple Neck’

Question: When my pediatrician writes “Neck is supple,” should I count the phrase as part of the musculoskeletal exam or the lymph system when tallying the E/M level? Alabama Subscriber Answer: Supple...

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Reader Question: POS Rule Change Has New Effective Date

Question: I’ve been expecting to see more information about CMS’s place of service (POS) rule with an October 1 implementation date. Have there been any updates? North Carolina Subscriber Answer: CMS...

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Reader Question: Know When You Can Report an E/M Service Along With Critical...

Question: My doctor saw a new patient in the office (99205) and then decided to admit her to the ICU. When he saw the patient later that same day, he Read More...

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Reader Question: Earn For Redo Spinal Procedures

Question: How do we report the following? Decompressive Laminectomies Total L3, partial L2-L4 Bilateral Forminotomy L2-3 and Redo L3-4 Only Dural Graft with PAM Is it correct to report 63047...

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Reader Question: New Year, New Insurance = New Verification

Question: How should I file a claim on a patient who has new coverage but has not received an insurance identification card yet? Georgia Subscriber Answer: Ideally, when patients call to Read More...

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Reader Question: Not All Pain is ‘Typical’

Question: What’s the diagnosis code for “atypical” chest pain? Answer: The ICD-9 index points to 786.59 (Other chest pain) for atypical chest pain. This code applies for any sort of discomfort, Read...

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Reader Question: Current Results Can Trump Previous HIV Positive Test

Question: A two-year-old child was admitted with pneumonia due to respiratory syncytial virus (RSV). The child’s history includes prematurity and being HIV positive. He was treated with Ribavarin and...

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Reader Question: Earn For Discontinued Procedures with Modifier 53

Question: Our neurologist was performing a trigeminal nerve block, 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) when he aborted it due to the needle penetrating the...

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Reader Question: Provider-Neutral Language Shouldn’t Impact Too Harshly

Question: Does our practice need to make any changes to our systems to accommodate the fact that CPT® 2013 changed so many descriptors from “physician” to “other qualified health care provider?”...

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Reader Question: Know the Path Codes for Scar Examination

Question: When our pathologist examines scar tissue, or tissue with a diagnosis related to scarring, can we bill 88305 if the specimen difficulty warrants the charge? Is there any time that Read More...

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Reader Question: 995.94 Isn’t the Only Code for SIRS Case

Reader Question: 995.94 Isn’t the Only Code for SIRS Case Question: The physician saw an inpatient with chronic lymphocytic leukemia who was admitted with tumor lysis syndrome due to chemotherapy and...

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Reader Question: Watch Details When Deciding Between Levels 4 and 5 E/M

Question: We have enough details for an encounter to reach these levels:  ·         HPI – detailed ·         ROS – complete ·         PFSH – complete ·         EXAM – 10 systems ·         MDM –...

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Choose 20552 or 20553 — Not 20605 — for Trigger Points

Question: The physician administered trigger point injections to fingers 2-5 on both the patient’s hands. He coded the procedure as 20605 x 8, but I don’t think that’s correct. What Read More...

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Reader Question: 36556 Use Depends on Termination Point

Question: My physician noted that he inserted a central line through the right femoral vein and a triple lumen catheter was advanced over the wires into the right femoral vein. To Read More...

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Reader Question: Each Hand Procedure Can Fetch You Payment

Question: In a patient with rheumatoid deformity in the right wrist, our surgeon did the following procedures:   1.   Extensor tenosynovectomy of extensor pollicis longus (EPL), second compartment,...

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You Be the Coder: Don’t Overlook “Separate Procedure” Lingo

Question: I have a clinic where the ENTs are claiming 92504 and 69210 should not be bundled. I remember one of the AAPC webinars had information stating that 92504 and Read More...

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Reader Question: Choose 17110 for Verruca Vulgaris Removal

Question: The physician used a laser to remove five lesions of verruca vulgaris on a patient. All lesions were buccal sulcus or membrane. Should I use 17110? Or is 40810 Read More...

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Reader Question: 92015-92140 and 92002-92014 Can Mix

Question: Can the special ophthalmological services be provided and reported with the general eye codes? Is modifier 25 required on the eye code if the two are performed together? Colorado Read More...

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Reader Question: Don’t Double Dip for Metabolic Panels

Question: A patient had a lab outpatient draw in the morning for BMP, and a lab ER draw later in the day for CMP. Can we bill for both of Read More...

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Reader Question: At First Those Earrings Looked Like An Accident, But...

Question: Can I please get other opinions on the correct ICD-9 code for an infected embedded earring in the ear? The earrings are stuck inside in the pinna, with small Read More...

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