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General Surgery Coding Alert
General Surgery Coding Alert
General Surgery Coding Alert - 2021; Volume 23, Number 12
CPT® Update:
Check out These Vascular Surgery 2022 Code Changes
Aorta coarctation repair marks additions for next year. With new options for reporting se...
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E/M Documentation:
4 Q&As; Clear Up MDM Confusion
See how to tally number and complexity of problems. With nearly a year of reporting E/M ...
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Vaccine Mandates:
Consider HIPAA Impact on COVID-19 Measures
Know what action you can take. If your surgery practice is considering a COVID-19 vacci...
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Reader Questions:
Engage Physician for Most Specific Dx
Question: I'm coding an op report for an EGD to treat esophageal varices (I85.00). But the...
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Reader Questions:
Scrutinize Time for Prolonged Service
Question: Our surgeon performed an extensive office evaluation and management (E/M) servic...
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Reader Questions:
Check Limb Length for Roux-en-Y
Question: The surgeon performed a laparoscopic gastric restrictive surgery for obesity by ...
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Reader Questions:
Practice HIPAA Compliant Faxing
Question: What are the HIPAA rules regarding using a fax to transmit lab test results? Ca...
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You Be the Coder:
Adjacent Tissue Transfer Stands Alone
Question: Our surgeon performed an excision of a 0.5 x 0.6 cm basal cell carcinoma on the ...
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General Surgery Coding Alert - 2021; Volume 23, Number 11
CPT® 2022:
Check Out New Surgery T-Codes and More Before Jan. 1
From transnasal EGD to POEM, you've got a lot to learn. Uncharacteristically, most of the...
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E/M:
Clarify 99211 for CPT® 2022
Note chronic care management updates, too. After nearly a year living with code revision...
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QPP:
Expect CMS to Sunset MIPS by 2027
And look for MVP reporting delay. With the six-year anniversary of the Quality Payment Pr...
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Reader Questions:
Up the Ante on Bilateral Documentation
Question: Our provider performed a bilateral ultrasound (US)-guided fine needle aspiration...
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Reader Questions:
Pinpoint COVID Vaccine Adverse Reaction Codes
Question: How do we code an adverse reaction to a COVID-19 vaccine that was noted by a phy...
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Reader Questions:
Use CMS-838 For Return Payment
Question: How can we be sure we're refunding the correct amount when a claims processing e...
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You Be the Coder:
Avoid Patient Payment for Screening Colonoscopy
Question: Our surgeon performed a screening colonoscopy for a 65-year old Medicare patient...
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General Surgery Coding Alert - 2021; Volume 23, Number 10
CPT® 2022:
Change Reporting Habits for Principal Care Management
See how CPT® and CMS clear the way. Changes to reporting E/M services didn't stop in 202...
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ICD-10-CM Update:
Incorporate New Dx Coding by Oct. 1
COVID-19 and GI changes top the list. Don't miss out on diagnosis coding updates — your...
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Compliance:
Get ‘Surprise Billing’ Disclosures in Place Now
You can still bill out-of-network balance — with permission. Known as the No Surprises ...
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Reader Questions:
Focus This Ovarian ‘Borderline’ Tumor Dx
Question: The pathology report for a left oophorectomy identifies “serous tumor of low ...
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Reader Questions:
Use Caution with Complication Billing
Question: Our surgeon performed a flexible sigmoidoscopy with the intention of performing...
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Reader Questions:
See If HIPAA Constrains Employers
Question: Can employers request employee lab test results for COVID-19 testing or does HIP...
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You Be the Coder:
Distinguish Venipuncture Codes
Question: What is the difference between venipuncture codes 36400-36410, 36420-36425, and ...
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General Surgery Coding Alert - 2021; Volume 23, Number 9
Vascular Surgery:
Master Your Swan-Ganz Coding with These 3 Tips
See when to bundle CVA. Many clinical scenarios call on vascular surgeons to use a diagno...
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Medicare Physician Fee Schedule 2022:
Proposed Rule Offers Telehealth Changes for Next Year
Look out for critical care bundles with global surgery. With no end in sight for the COVI...
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Compliance:
Silence HIPAA Misconceptions About PHI Disclosure
Give patients requested records. Keeping protected health information (PHI) private is g...
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You Be the Coder:
Distinguish Modifiers 66 and 62
Question: Our general surgeon worked as part of a surgical team for a liver transplant in ...
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Reader Questions:
Time is On Your Side
Question: I have a procedure note indicating that the provider performed an outpatient eva...
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Reader Questions:
Go for Modifier 58 Without Complication
Question: Our surgeon excised a 1.2 cm melanoma, but returned the patient to surgery three...
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Reader Questions:
Update PHE Deadline
Question: What is the current status of the PHE for COVID-19, and when can we expect it to...
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Reader Questions:
Dictate Dx from Pathology Report
Question: We're coding an op report for an excised polyp from the rectosigmoid junction th...
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General Surgery Coding Alert - 2021; Volume 23, Number 8
Integumentary Case:
Distinguish Skin Biopsy Vs. Excision Based on Intent
Choose procedure code with pathology report in hand. Integumentary procedures hold lots o...
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Evaluation and Management:
Turn to Virtual Check-In for Telephone-Only E/M
Distinguish G-codes from 99441-99443. While you may have focused on telehealth services d...
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Documentation:
Query Surgeons with Confidence for Clean Claims
Look to CMS for guidance. When you need to clarify an op report with your surgeon, you sh...
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You Be the Coder:
Avoid Enteroscopy Codes for Duodenum ‘Peek’
Question: We have an op report for a procedure described as a diagnostic EGD for gastroeso...
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Reader Questions:
Recognize Different MDM Tables
Question: Can we use examples from the Table of Risk currently provided by the Centers for...
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Reader Questions:
Halt Modifier 63 With Infant Cutdown
Question: Our surgeon attempted percutaneous venipuncture for a 2 months old infant weighi...
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General Surgery Coding Alert - 2021; Volume 23, Number 7
Endoscopic Surgery:
Dominate US Guided GI Procedure Coding With These 4 Steps
Don't unbundle separate steps. Whether down the hatch or up the other end, CPT® provides...
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E/M 2021:
Grab Our Experts’ Take on Revised 99202-99215 Implementation
See how MDM focus has changed everything. With completely different descriptors and guide...
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HIPAA:
Vet Your BA’s HIPAA Harmony Before Hiring
Their non-compliance may be your liability. As a surgeon, you're a covered entity (CE) ...
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You Be the Coder:
Look for Colonoscopy Medical Necessity
Question: Our surgeon performed a colonoscopy and internal hemorrhoidectomy by band ligati...
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Reader Questions:
Follow Excludes Note to C7A.0
Question: Our surgeon performed an ileum biopsy, and the pathology report states a diagnos...
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Reader Questions:
Get the Lowdown on POS Codes
Question: Could you please clarify what the POS codes are that surgeons might use and how ...
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Reader Questions:
Abide by State Regulations for Minors
Question: We have a 17-year-old patient who has requested that we not discuss her care wit...
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Reader Questions:
Look for Separate ECMO Initiation
Question: Are codes 33948 and 33949 the only codes available for ECMO services? Louisiana...
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General Surgery Coding Alert - 2021; Volume 23, Number 6
Abdominal Surgery:
3 Tips Demonstrate Key Terms You Need to Know for Splenectomy Coding
Master ‘separate procedure' rules to perfect your claims. The spleen manages to get in...
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Surgical Case:
Nail This Splenectomy Coding Scenario
Take what you've learned in “3 Tips Demonstrate Key Terms You Need to Know for Splenecto...
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E/M:
Here’s Why the Payer Impacts Your Prolonged Service Coding
Only outpatient codes take G2212 or +99217. Depending on your payer(s) for outpatient ev...
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Reader Questions:
Decipher Breast Note for ‘Wide Excision’
Question: I'm coding an op report and the surgeon describes the breast procedure as “wid...
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Reader Questions:
Respond to MAC Overpayment Claim
Question: We received a “demand letter” from our MAC claiming that we were overpaid. W...
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Reader Questions:
Beware Separate Lymph Node
Question: Our surgeon removed tonsils and adenoids for a 6 year old patient. The op report...
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Reader Questions:
Implement Mobile Device HIPAA Security
Question: Could you give some tips to help secure our mobile devices, meet HIPAA requireme...
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You Be the Coder:
Distinguish GERD Esophageal Procedures
Question: Our surgeon performed a procedure to control the esophageal sphincter to treat a...
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General Surgery Coding Alert - 2021; Volume 23, Number 5
COVID-19 PHE:
Manage Telehealth Compliance and Coding with 3 Tips
Use these resources for clean claims. With hundreds of codes added to the list of service...
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Master Modifiers:
Choose Between 52, 53 for Halted Surgery
The devil is in the ‘stopped service' details. When your surgeon has to stop a surgery ...
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Practice Management:
Adhere to OSHA COVID-19 Guidelines
Protect back-office staff, too. For employee safety and compliance purposes in your gener...
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Reader Questions:
Maximize CS Modifier Use
Question: We've been using modifier CS for Part B claims during the PHE, but I'm not clea...
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Reader Questions:
Capture Burn Case Coding Details
Question: Our surgeon treated a 14 year old patient in the emergency room who had a second...
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Reader Questions:
Phone Call May Warrant Prolonged Service
Question: Our surgeon performed an E/M service over the phone that lasted 55 minutes. Can ...
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You Be the Coder:
Scope Guides Anorectal Biopsy Code
Question: Which code should we use for a case when the surgeon performs an anorectal biops...
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General Surgery Coding Alert - 2021; Volume 23, Number 4
CPT® 2021:
Master New Breast Reconstruction/Repair Guidelines
Learn which steps you can separately report. In addition to nearly 20 code changes we elu...
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HCPCS Level II:
Don’t Miss G Codes Your Surgery Practice May Use
Capture prolonged service pay and more for Medicare beneficiaries. While you're getting u...
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Compliance:
Spotlight General Surgery Billing Errors from CERT Report
See specific documentation pitfalls. Medicare Part B claims showed nearly a 3 percent er...
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Reader Questions:
Capture ICD-10 Codes Post-Whipple
Question: A patient developed hypoinsulinemia and diabetes after our surgeon performed a W...
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Reader Questions:
Expect PHE Through 2021
Question: We're worried about being caught off guard if the COVID-19 public health emergen...
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You Be the Coder:
Classify Anus Tag or Hemorrhoid
Question: The patient presented for a colonoscopy and also mentioned a troublesome externa...
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General Surgery Coding Alert - 2021; Volume 23, Number 3
CPT® 2021:
Master Lung Biopsy Coding Changes
Use modifiers for multiple specimen extractions. When your general surgeon performs a lun...
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Compliance:
Grasp CAA and MPFS Impacts on Your Surgery Practice
There's more to know than E/M. In General Surgery Coding Alert Vol. 23, No. 2, you read t...
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HIPAA:
Keep Remote Work Secure During Pandemic
Don't let patient privacy lapse. You need to keep patient protected health information (P...
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Reader Question:
Use New Prostate Ablation Code
Question: I've heard we can no longer use code C9747, so how should we report prostate abl...
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Reader Questions:
Hone Modifier 22 Skills
Question: Is it correct that we should use modifier 22 only if the surgeon documents at le...
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Reader Questions:
Look for Medicare Colonoscopy Coverage Change
Question: Is there a change this year in how Medicare pays for colorectal cancer screening...
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Reader Questions:
Use Form 3508S for PPP Loan Forgiveness
Question: How can we apply for loan forgiveness under the Paycheck Protection Act? Monta...
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Reader Questions:
Find Dedicated Endoscopy Injection Codes
Question: Our surgeon injected India ink to mark a lesion during upper GI endoscopy. How s...
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You Be the Coder:
Count Test Order and Review for MDM
Question: If the surgeon bills an E/M visit based on medical decision making (MDM), not ti...
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General Surgery Coding Alert - 2021; Volume 23, Number 2
Final Rule:
Prepare Your General Surgery Practice for Big Medicare Pay Decrease
E/M increase won't balance conversion factor decline. The release of the 2021 Medicare Ph...
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CPT® Update:
Upgrade Your Vascular Surgery Code Choices for 2021
T-codes and VAD overhaul lead the charge. With major changes to percutaneous ventricular ...
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ICD-10:
Conquer Colon Polyp Dx Coding for Clean Claims
Treatment decisions rest on accuracy. Missing the correct diagnosis code from your surge...
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Reader Questions:
Understand 99072 Opportunities and Limits
Question: We've heard there's a new CPT® code for reporting additional practice expe...
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Reader Questions:
Question Hospital Inpatient Telehealth
Question: Can we report inpatient telehealth evaluation and management (E/M) services to M...
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Reader Questions:
Dissect Office or Consult E/M Choice
Question: Our surgeon examined a patient in the office and sent a report about the patient...
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Reader Questions:
Know When to Use ‘Independent Historian’
Question: Our surgeon evaluated an infant in the office for correction of a birth defect. ...
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You Be the Coder:
Peel Back Answers for GERD Evaluation
Question: While performing an esophagoscopy, our surgeon placed a Bravo capsule to monitor...
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General Surgery Coding Alert - 2021; Volume 23, Number 1
E/M 2021:
Use This FAQ to Strengthen Inpatient Coding Skills
Time is different in the hospital. Just because you're focused on CPT® 2021's big change...
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CPT® 2021:
Update Your Breast Reconstruction/Repair Coding Know-How
Drill down to significant code revisions. With 15 revised codes and two code deletions, p...
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HIPAA:
Protect Patient Information Beyond the Chart
Understand compliance relief during PHE. Even though you can share patient protected hea...
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Reader Questions:
Clarify ‘Correlates’ and ‘Consistent’ Dx Terminology
Question: When I'm assigning a diagnosis code, I'm always confused when the surgeon docume...
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Reader Questions:
Select Most Specific EGD Procedure Code
Question: A patient was referred to our surgeon for suspected esophageal cancer or abnorma...
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Reader Questions:
Illegible Signature?
Question: What can we do our surgeon's signature is illegible? Oregon Subscriber Answer...
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You Be the Coder:
Beware Swan-Ganz Bundles
Question: Our surgeon performed a Swan-Ganz procedure, placed a central line through the s...
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