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General Surgery Coding Alert

CPT® 2023:
Embrace E/M Shift to Time or MDM
See which codes may impact general surgery practices. Even if you've finally gotten used... Read more
Case Study:
Use 3 Quick Scenarios to Focus Hernia Procedure, Dx Coding
Notice CPT® 2023 abdominal hernia change. When surgeons treat patients for hernia proble... Read more
CMS vs CPT®:
Confront Agency Differences for Reporting Prolonged Services
Master 3 new HCPCS Level II codes. CPT® 2023 changes how you should code prolonged serv... Read more
Reader Questions:
Code Replacement G-tube Case
Question: How should we code the following procedure? The surgeon replaced a dislodge... Read more
Reader Questions:
Use Time for This E/M
Question: Our surgeon saw a new patient with a chief complaint of left shoulder pain.... Read more
Reader Questions:
Recognize HIPAA When Faxing Results
Question: Sometimes a client or patient requests faxed medical records. What are the ... Read more
You Be the Coder:
Use Two Codes for Combined Technique
Question: Our vascular surgeon accessed the occluded femoral vein through a tiny inci... Read more
CPT® 2023:
Grasp Fistula Creation Code Distinctions
See how procedure and payer may guide correct code choice. Two new fistula creation codes... Read more
E/M CPT® Update:
Hone Your Office/Outpatient Consultation Coding Skills for 2023
Use this key modifier for clean claims. When your surgeons perform office and outpatient ... Read more
Compliance:
Follow This Advice for Clean Medicare Claims
See how billing error codes can guide you. You know it's wise to learn from your mistake... Read more
Reader Questions:
Find New Ways to Use Modifier 25
Question: I've heard that we can use modifier 25 to bill two E/M visits on the same date o... Read more
Reader Questions:
Don’t Code What’s Not Documented
Question: We have an op note that states “patient presents with sharp stomach pain.” T... Read more
Reader Questions:
Go Soft on This Neoplasm Code
Question: What is the correct code for leiomyosarcoma of the sigmoid colon? I have found d... Read more
You Be the Coder:
See What ‘Replacement’ Tube Includes
Question: Could you please clarify how to code for percutaneous insertion of tubes, such a... Read more
CPT® Sneak Peek:
Jumpstart Your 2023 Readiness With This Coding Preview
Prep for hernia repair overhaul. In just three short months you'll be using CPT® 2023 to... Read more
ICD-10-CM:
Know When and How to Use New SDoH Codes
Make sure to report social factors that impact care. When your surgeon notes that issue... Read more
Technology Support:
Appraise Shared Drive System for Secure Remote Work
Make sure HIPAA compliance is your focus. Following the pandemic disruption that sent man... Read more
Reader Questions:
Don’t Let Endoscopy Fool You
Question: Using a nasogastric tube, the surgeon inflated the abdomen, then punctured... Read more
Reader Questions:
Look for Ongoing Medical Records Review
Question: We'd heard that medical records reviews were on hold due to the COVID-19 PH... Read more
Reader Questions:
Use This Modifier for Return to OR
Question: Following a recent colectomy, the surgeon had to return to the OR for sympt... Read more
Reader Questions:
Know How to Report Long COVID
Question: Our surgeons have noted that they sometimes encounter patients who have sym... Read more
You Be the Coder:
Devil is in the Details for Lesion Excision Coding
Question: Our surgeon excised a skin lesion that measured 1 cm x 0.5 cm with a 0.2 cm... Read more
Integumentary Procedures:
Spotlight Common Skin Biopsy Errors With 3 Cases
Use this coding trick to avoid costly multiple-biopsy mistakes. Using skin-biopsy codes ... Read more
Medicare Physician Fee Schedule:
Beware Proposed Rule Conversion Factor Decrease for 2023
See how changes impact general surgery. Practices may have hoped that rising inflation... Read more
Compliance:
Increase Your PHE Fraud Awareness With This OIG Report Overview
Feds Focus on PHE Tricksters and Recover Pay. COVID-19-related fraud and abuse are the p... Read more
Reader Questions:
Follow ‘Global Package’ Billing Requirements
Question: When a surgeon sees a patient and schedules a surgery, can we bill another ... Read more
Reader Questions:
Check Mastectomy Bundling Rules
Question: Our surgeon placed Savi Scout reflectors to localize the tumor as the initi... Read more
Reader Questions:
Dont Let Records Disposal Trash HIPAA Compliance
Question: Do we need to follow specific rules regarding records disposal under HIPAA,... Read more
You Be the Coder:
Avoid Dx Terms of ‘Uncertainty’
Question: In the office, our surgeon aspirated a painless “lump” behind the patie... Read more
ICD-10-CM 2023:
Keep Medical Necessity Accurate With New Dx Codes
You'll need to start using these codes Oct. 1, 2022 Don't get overwhelmed with more than ... Read more
Table:
Clip and Save Endometriosis Dx
This table provides a breakdown of the new ICD-10-CM 2023 endometriosis codes that go in e... Read more
Coding Strategies:
Let Extent of Excision Guide Your Tongue Procedure Reporting
Mistaken identity could sacrifice pay. Surgeons may perform tongue biopsies, lesion excis... Read more
Reader Questions:
Convert This Screening Colonoscopy to Diagnostic? Not So Fast.
Question: During a screening colonoscopy, the surgeon documented finding hemorrhoids... Read more
Reader Questions:
Look For These HIPAA Resources
Question: We've been experiencing an increase in phishing and are aware of reports of... Read more
Reader Questions:
Use This CMS Acronym Glossary
Question: We have new staff in our office who are having a hard time maneuvering the ... Read more
You Be the Coder:
Distinguish Bone Marrow Biopsy and Aspiration
Question: When I read an op note for a bone marrow procedure, I'm confused about the ... Read more
Surgery:
Master GI Tube Coding In 6 Steps
Find the coding secret for gastro-jejunostomy tube insertion When you see an op note that... Read more
E/M Skills:
Focus Your E/M Code Selection With MDM Shortcuts
Tip: Undiagnosed conditions should count in your calculations. If you still have some un... Read more
Compliance:
Fix Your Duplicate Claim Denial Problem with Modifiers
Look for medically necessary repeats. Sometimes your surgeon or another surgeon repeats... Read more
Reader Questions:
FNA: Understand Resequenced Codes
Question: When I'm trying to find an FNA procedure code in the CPT® manual, I find i... Read more
Reader Questions:
Choose Complete Esophagoscopy Code
Question: During an esophagoscopy procedure, the surgeon performs balloon dilation to... Read more
You Be the Coder:
Surgeon May Have Final Say in Dx Coding
Question: The surgeon submitted an esophageal biopsy taken during an esophagogastrodu... Read more
Wound Care:
Spotlight Wound-Procedure Distinctions to Choose the Right Code
Failed attempts may lead to negative pressure therapy. When your surgeon treats int... Read more
ICD-10-CM:
Don’t Let Numerous Codes Be a Pain in the Gut
Learn to distinguish 27 abdominal pain code choices. When you face an office or op note w... Read more
Documentation:
Get Your Medical Records in Top Shape With These 3 Steps
Establish parameters for timeliness to capture detail. Poor medical record hygiene may l... Read more
Implement NCQA Documentation Guidelines for Optimum Medical Record
“Get Your Medical Records in Top Shape With These 3 Tips” on page 5 exhorted you to ke... Read more
Reader Questions:
File Final Dx Code Instead of Symptoms
Question: Our surgeon performed an EGD for a patient complaining of recurrent heartb... Read more
Reader Questions:
Abide By Certain PHI Restriction
Question: Are we required to honor a patient's request to limit or restrict disclosu... Read more
You Be the Coder:
Vein, Procedure, and History Needed for ‘Stripping’ Claim
Question: Our surgeon performed “vein stripping” in the patient's right calf due ... Read more
Case Highlights:
Put Some Skin in the Game With These Lesion Coding Scenarios
Don't miss the musculoskeletal options. With so many code choices for surgical procedure... Read more
Focus on Modifiers:
Find the Best Choice for Your Surgeons’ Partial Services
Use this modifier for one side of a bilateral service. When you can't quite report a pr... Read more
Compliance:
Use Fed Toolkit To Halt HIPAA Breach Vulnerability
Up your cybersecurity game for your surgical practice. Security breaches were up in 2021... Read more
Reader Questions:
See if Separate Lesion Allows Separate Code
Question: During a screening colonoscopy, the surgeon biopsied a suspicious area in t... Read more
Reader Questions:
Code This Scar Revision Cancer Case
Question: Following a mastectomy one year ago, the patient returns for a scar revisio... Read more
Reader Questions:
Add Debridement Areas
Question: The surgeon performed debridement for a burn case that involved removing es... Read more
You Be the Coder:
Define Stable Chronic Illness
Question: Our surgeon performed sinus surgery for a patient referred due to chronic s... Read more
GI Procedures:
Sort 13 Inguinal Hernia Repair Codes to 1 Correct Choice: Here’s How
See how adding hydrocele removal changes things. If your heart sinks when you see an op ... Read more
Clip and Save:
Chart Your Inguinal Hernia Repair Codes With This Handy Table
Use the following table to drill down through all the details from the op report that will... Read more
Vascular Cases:
Take This Quiz to Master ICD-10-CM Coding for Septic Embolism
Always target a primary diagnosis. When your vascular surgeon treats affected tissues r... Read more
HIPAA:
Take ‘Right of Access’ Seriously or Expect Enforcement Action
See whose record requests you must honor. With six out of seven HIPAA enforcement settle... Read more
Reader Questions:
Master Post-Bariatric Skin Removal Coding
Question: Our surgeon performed a procedure for a patient who had lost considerable w... Read more
Reader Questions:
Stay Focused on H&P Documentation for Modifier 25
Question: Do the recent changes to E/M codes alter the way we use modifier 25? Calif... Read more
Reader Questions:
Keep Compliant With HIPAA Risk Analysis
Question: Can we switch to gap analysis of how we implement HIPAA compliance instead ... Read more
You Be the Coder:
Revise Bilateral Ovarian Cancer Dx
Question: Our surgeon performed a bilateral oophorectomy and the pathology report sho... Read more
Integumentary System:
Hone Your Pilonidal Disease Coding Skills for Clean Claims
Surgeon's level of effort counts. With few hard and fast rules to focus pilonidal disease... Read more
Medicare Coverage:
Correctly File Screening Colonoscopy Claims with These Tips
CMS to phase out coinsurance for screenings that turn diagnostic. When your surgeon perf... Read more
E/M:
Avoid Observation Coding Pitfalls or Risk Denials
Remember Medicare vs. private-payer rules. Somewhere between inpatient and outpatient se... Read more
Reader Questions:
Document Medical Necessity for Appendectomy
Question: Our surgeon performed a Roux-en-Y bariatric surgery procedure. During the ... Read more
Reader Questions:
Drill Down to Details for Central Line Coding
Question: The surgeon inserted a central line with a subcutaneous port in the jugular vein... Read more
Reader Questions:
Check Closure and Ostectomy Details for Pressure Ulcer Case
Question: How should we code the surgeon's work for excising an ischial pressure ulce... Read more
You Be the Coder:
Clarify Coding for Drug Delivery Device
Question: Our surgery practice has access to a 3-D printer which we use to create biodegra... Read more
CPT® 2022:
Expand Your GI Endoscopy Coding Options This Year
Greet Category III codes for more options. From transnasal to capsule endoscopy and more... Read more
Final Rule:
Grasp MPFS 2022 Changes that Impact Your General Surgery Practice
Keep telehealth coverage in line with this update. With rulings on shared evaluation and ... Read more
Reimbursement:
Feds Rescue Medicare Providers from Massive Pay Cuts
Start with 3% CF increase for 2022. With two years of COVID hits to healthcare providers... Read more
Reader Questions:
Highlight Preventive Colonoscopy
Question: We have a case in which the surgeon performed a screening colonoscopy, but found... Read more
Reader Questions:
Capture US Guidance with Arterial Catheterization
Question: Our surgeon performed a percutaneous arterial catheterization for a transfusion ... Read more
Reader Questions:
Foil Keylogger Software
Question: What exactly is keylogger software, and how can we avoid this type of security b... Read more
Reader Questions:
Watch the Minutes for E/M Prolonged Services
Question: Documentation for a new patient office E/M service shows high-complexity medical... Read more
You Be the Coder:
Clarify ‘Pleural Drainage’ Procedure
Question: We have an op note in which the surgeon drained pleural fluid and performed a ne... Read more
CPT® 2022:
Here’s Why You Can’t Miss This Foreign-Body Guideline Change
See how this affects coding for breast implant removal. Who knew a little paragraph defi... Read more
Upper GI Procedures:
Missing Details in EGD Op Report Means Losing Pay
Focus on ‘sample collection' vs. ‘biopsy.' When your surgeon performs an esophagogast... Read more
Compliance:
Master These Appeals ‘Best Practices’ for Your Surgery Group
Focus the reason for your request. Being able to appeal claims that Medicare denies is a ... Read more
Reader Questions:
Distinguish ‘Total’ or ‘Lobectomy’ for Thyroid Case
Question: Our surgeon performed a left substernal thyroid lobectomy by cervical approach. ... Read more
Reader Questions:
Decipher Details for Ulcer Dx
Question: The surgeon performed an EGD with biopsy for a patient with burning, sharp pain ... Read more
Reader Questions:
Unravel Bilateral Breast Coding Conundrum
Question: We received a Medicare denial for a claim involving two units of 19083 with modi... Read more
Reader Questions:
Do This to Distinguish ‘New Patient’ E/M
Question: If a patient sees one surgeon in our practice, then one year later sees a differ... Read more
You Be the Coder:
Learn MUE Limits and Options
Question: Could you please clarify what “MUE” is and how it might impact my coding? G... Read more
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