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General Surgery Coding Alert

CPT® 2021:
Answer 3 Questions to Test Your E/M 2021 Coding Preparedness
Learn how +99417 fits in. If you've been focused on keeping up with the COVID-19 rules t... Read more
COVID-19:
Don’t Miss Recent Exceptions that Impact Your General Surgery Practice
Check out PHE-related regulations. Even as COVID-19 cases are ramping up in many location... Read more
Practice Management:
Look for Medicare AAP Recoupment Relief
Does your practice have pandemic-related financial hardship? If your general surgery pra... Read more
You Be the Coder:
Distinguish Proctosigmoidoscopy and Anoscopy
Question: Our surgeon used a rigid scope to rule out colitis for a patient complaining of ... Read more
Reader Questions:
Site Drives Coding for Procedure Plus Hernia
Question: When billing multiple surgeries, such as a laparoscopic cholecystectomy and hern... Read more
Reader Questions:
Know Data Elements for Eligibility
Question: We're trying to verify a Medicare beneficiary's eligibility with our MAC using a... Read more
Reader Questions:
Use These Scam Protection Tips
Question: What's the difference between phishing and vishing, and how can we protect ourse... Read more
Reader Questions:
Beware Breast-Plus-Lymph Pitfall
Question: The op report documents excision of the left upper-outer breast quadrant and a c... Read more
Reader Questions:
Calculate Time for Office E/M in 2021
Question: 've heard that if we're reporting E/M services based on time in 2021, we can cou... Read more
General Surgery:
‘PICC’ the Best Code for Venous Access
Use this Q/A flowchart to accurately report PICC procedures. When you face an op report f... Read more
Physician Fee Schedule:
Prepare for Large 2021 Conversion Factor Cut
Expect changes due to COVID-19, too. The Medicare Physician Fee Schedule (MPFS) 2021 prop... Read more
ABN:
Update Beneficiary Notification to Protect Your Surgeon’s Bottom Line
Don't let deadline reprieve fool you. Not getting paid for a surgical procedure because y... Read more
You Be the Coder:
Get Details for Cyst Fluid Specimen Case
Question: Our surgeon obtained a sample of fluid from an ovarian cyst under ultrasound gui... Read more
Reader Questions:
File New Claim if ‘Unprocessable’
Question: We received an “unprocessable” claim from our MAC. Can we appeal this? Ohio... Read more
Reader Questions:
Maintain NPI Across State Lines
Question: Our general surgery practice is moving from Louisiana to Texas. Do our surgeons ... Read more
Reader Questions:
Beware Adhesiolysis Bundles
Question: During a splenectomy procedure, the surgeon documents encountering dense adhesio... Read more
ICD-10-CM:
Learn Surgery-Relevant Diagnosis Code Changes for 2021
Start using new codes Oct. 1. Now's the time for your general surgery practice to solidif... Read more
Diagnosis Coding:
Track ICD-10-CM 2021 Notes and Guidelines for Accurate Reporting
Look for index changes, too. You'll need to use the new and revised ICD-10-CM codes on ... Read more
Distinct Procedures:
Move Surgical Scenarios from 59 to X{EPSU}
Regard NCCI Policy Manual examples. Maybe you've recently received a payer notice regar... Read more
You Be the Coder:
Diagnosis Leads to Specific Procedure Code
Question: The surgeon excised a 6.6 x 4.6 x 3.4 cm pelvic mass attached to the lesser pelv... Read more
Reader Questions:
Contact COVID-19 Patients for Plasma Donation
Question: We've ordered COVID-19 testing for many patients, and have identified some patie... Read more
Reader Questions:
Look for Time or MDM in 2021
Question: Will we have to base every E/M coding decision on only time and medical decision... Read more
Reader Questions:
Do This When Telehealth Turns Office Visit
Question: Our surgeon had a telehealth visit with a patient that resulted in the patient c... Read more
Reader Questions:
Find Code Choices for J-Tube Without Guidance
Question: I know there are G-tube replacement codes for procedures without imaging, but ho... Read more
Bundling Rules:
Keep an Eye on NCCI When Billing Thyroid FNA Cases
Pay special heed to multiple-lesion guidance. Coding thyroid fine needle aspiration (FNA)... Read more
E/M Update:
Deconstruct Table of Elements to Master MDM in 2021
Focus on your surgeon's analysis and management. As medical decision making (MDM) takes ... Read more
Compliance:
Focus on 5 Interoperability Policies
Fed says, prioritize patient access. With all the focus on COVID-19, maybe you missed the... Read more
You Be the Coder:
Capture 3 Steps for Mastectomy Case
Question: Our surgeon performs a partial mastectomy and if the deformity is too big then h... Read more
Reader Questions:
Find 'Debulking' Code for Recurrent Tumor
Question: The surgeon excised a 6.6 x 4.6 x 3.4 cm pelvic mass attached to the lesser pelv... Read more
Reader Questions:
CMS Restarting Medical Review
Question: I've heard that CMS is suspending medical reviews for the duration of the COVID-... Read more
Reader Questions:
Modify Cancelled Surgery
Question: Our surgeon had to cancel a surgery midway through a procedure for the patient's... Read more
Reader Questions:
Describe Symptom, Procedure EGD Details
Question: A patient was diagnosed with sliding hiatal hernia based on X-ray findings, and ... Read more
Vascular Surgery:
4 Tips Focus Infrarenal Aorta Endograft Coding
Distinguish cases involving rupture. When your surgeon performs an endograft procedure in... Read more
ICD-10-CM:
Sharpen Your Skills With This Diagnosis Coding Quiz
Don't miss exception to ‘code confirmed Dx first' rule. Perfect procedure coding won't ... Read more
HIPAA:
Defer to OCR Privacy Reminder in Age of COVID-19
Don't shirk ‘prior authorization' requirement. In case your surgery practice lost its f... Read more
Reader Questions:
Use COVID-19 Signifiers for 'Formal Waiver' Claims
Question: Are Medicare providers supposed to be using the CR modifier or DR condition cod... Read more
Reader Questions:
Dx Shows Medical Necessity for Scar Revision
Question: A year after our surgeon excised a basal cell carcinoma on a patient's right lit... Read more
Reader Questions:
Decipher Diagnosis for EGD Findings
Question: The surgeon performed an EGD and described the distal esophagus as “appearing ... Read more
You Be the Coder:
Focus on Nail Matrix for Code Selection
Question: Our surgeon treated a patient in the office whose big toenail was almost co... Read more
COVID-19 PHE:
Master Billing Alternatives for Non-Video Patient Contact
Learn CMS expanded coverage during pandemic.  If healthcare providers from your gene... Read more
Removal:
Master Debridement Coding with 4 Tips
Watch for bundling issues. So many surgical cases involve debridement of damaged tissue, ... Read more
Coverage Update:
Look for More CMS Regulatory Relief During COVID-19 Pandemic
Don't miss changes beyond telehealth. The continued onslaught of policy revisions may pro... Read more
Reader Questions:
Find HHS-Approved Communication Products for Telehealth
Question: How can I find out which telecommunication products are allowed for telehealth v... Read more
Reader Questions:
Focus Comprehensive History Requirements
Question: I have a surgeon's note for an office visit that includes a chief complaint, an... Read more
Reader Questions:
Learn Modifier CS Rules
Question: When should we use modifier CS as it relates to COVID-19? Codify Subscriber An... Read more
Reader Questions:
Modifiers Save E/M, Aspiration Encounter
Question: An established patient reports with right knee and thigh pain. During an E/M ser... Read more
Update E/M 2021:
Focus on MDM and Time Next Year
Learn new and established office patient code changes. You and your surgeons will need to... Read more
Telehealth:
Master New Guidance for COVID-19 Telehealth Exceptions
Don't miss POS detail. During the public health emergency (PHE) related to the COVID-19... Read more
Bilateral Basics:
Do This Before Appending Modifier 50
Tip: Start with the descriptor. When your general surgeon performs a bilateral surgery,... Read more
You Be the Coder:
Watch NCCI Edits for EGD Case
Question: Our surgeon performed an EGD with lesion ablation. The op note also documents th... Read more
Reader Question:
Does New Practice Nix Established Patient?
Question: When a physician joins a new practice and sees patients from the former practice... Read more
Reader Question:
Update Modifier CR Use
Question: I've heard we are supposed to be using modifier CR on COVID-19 related claims. C... Read more
Reader Question:
Laser Focus Reason for Visit
Question: A patient presented in the surgeon's office for an evaluation of a suspected her... Read more
ICD-10-CM:
Hasten Your COVID-19 Dx Coding Know-How
Distinguish suspected versus positive cases. Because your surgeons may encounter and tre... Read more
Diagnosis:
Put 'Signs and Symptoms' Coding in its Place
Overcome four falsehoods that hamper your reporting. When you face a case report with n... Read more
CERT Report:
Highlight General Surgery 'Improper Payments'
E/M leads coding trouble spots. Even if your surgeons strive for excellent documentation ... Read more
You Be the Coder:
Distinguish LEEP Procedures
Question: Our surgeon performed a colposcopy and used a loop electrocautery excision of ce... Read more
Reader Question:
Don't Miss Common Duct Exploration
Question: The op note for a laparoscopic cholecystectomy documents visualizing the cystic ... Read more
Reader Question:
Bundle Hernia Repair
Question: Our surgeon performed a laparoscopic liver biopsy, and during closure, the surge... Read more
Reader Question:
Exercise Caution When Changing Documentation
Question: When we see that documentation doesn't match a code choice, we usually go b... Read more
Integumentary Procedures:
3 Tips Guide Coding for Skin Substitute Grafts
Grasp measurement rules. Replacement material, graft size, multiple wounds … all these ... Read more
ICD-10-CM:
Focus Appendicitis Dx Coding
Don't miss pregnancy impact. When your surgeon treats a patient with appendicitis, you ... Read more
HIPAA:
Hone Your Breach Compliance Know-How
Planning can reduce consequences. Even a minor breach of patient protected health informa... Read more
Reader Question:
Critical Care is Unscheduled
Question: When our surgeon rounds on a patient in the critical care unit, can we use the c... Read more
Reader Question:
Properly Sequence External Cause
Question: When and how should we use external cause codes? Codify Subscriber Answer: You... Read more
You Be the Coder:
Learn Catheter Placement Basics
Question: We have a new surgeon in our practice who specializes in vascular surgery, and I... Read more
CPT® 2020:
Clarify AFG Breast Reconstruction
15771, +15772 stand alone. If your surgeon uses autologous fat grafting (AFG) for breast ... Read more
Evaluation and Management:
Prepare for 2021 E/M Changes That Will Affect Your Surgery Practice
Grasp now and then with case example. How your surgeons report outpatient E/M services is... Read more
Post-Op Period:
3 Tips Ensure Perfect Modifier 78 Claims
Distinguish 58, 79. When your surgeon performs a procedure during the postoperative perio... Read more
Reader Question:
Pick Specific Dx Code for HIT
Question: Our surgeon performed a venous thrombectomy for a patient with a diagnosis of he... Read more
Reader Question:
Details Guide Esophageal Dilation Case
Question: How should we code the following esophageal dilation case that includes both a b... Read more
You Be the Coder:
Avoid 51 Modifier
Question: Our surgeon performed a percutaneous breast biopsy, placing a marker and using s... Read more
Integumentary System:
4 FAQs Focus Skin Biopsy Coding
One trick keeps multiple biopsy claims clean. A year into the skin biopsy-code overhaul, ... Read more
Case Study:
Break Down Esophageal Case for Appropriate Code(s)
Prosthesis placement is just one step. When your surgeon faces an encounter layered with ... Read more
E/M:
Master Critical Care Guidelines for Clean Claims
Time is on your side. When your surgeon treats a patient who is in critical condition, yo... Read more
Reader Question:
Find the Missing 'Payable Diagnoses'
Question: We've always turned to our Medicare contractor's LCDs to find a list of payable ... Read more
Reader Question:
Wait for It — Final Dx
Question: Our surgeon excised a “lump” from a patient's right forearm based on a reque... Read more
You Be the Coder:
Don't Miss Laparotomy Pay
Question: Our surgeon returns a patient to the OR four days following an open partial cole... Read more
CPT® Update:
Renew Vascular Coding Know How for 2020
Check out codes for pericardiocentesis and more. Keep your circulatory claims in tip-top ... Read more
2020 MPFS:
See How Final Rule Affects Your General Surgery Practice
Follow care-management modifications. E/M coding and payment updates lead the charge of M... Read more
Physician Fee Schedule:
Countdown to E/M Overhaul
The Medicare Physician Fee Schedule (MPFS) final rule contains no surprises regarding when... Read more
Reader Question:
Avoid Elliptical Measure for Lesion Excision
Question: Last month you answered a reader question about coding malignant lesion excision... Read more
Reader Question:
Factor Time Into Online E/M
Question: How should we report online E/M service in 2020 if it's true that CPT® is delet... Read more
Reader Question:
Protect ePHI
Question: Our office wants to use electronic faxing for medical records, and we want to kn... Read more
You Be the Coder:
Code to Capture Screening Intent
Question: While performing a screening flexible sigmoidoscopy, the surgeon detected and re... Read more
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