General Surgery Coding Alert
Procedure Coding:
Take These 5 Tips, Accurately Code Upper GI Scope Exams
Hint: Determine how far the scope went. According to one study, the average general surge... Read more
Take These 5 Tips, Accurately Code Upper GI Scope Exams
Hint: Determine how far the scope went. According to one study, the average general surge... Read more
Coding Deep Dive:
Answer the How, What, When, and Why for Preoperative Evaluations
Don't forget to check for comorbid conditions. Knowing how to navigate and select all of... Read more
Answer the How, What, When, and Why for Preoperative Evaluations
Don't forget to check for comorbid conditions. Knowing how to navigate and select all of... Read more
Practice Management:
Improve Provider, Coder, Biller Relations, Improve Outcomes and Revenue
Three different roles, the same shared goals. In her presentation “Documenting and Codi... Read more
Improve Provider, Coder, Biller Relations, Improve Outcomes and Revenue
Three different roles, the same shared goals. In her presentation “Documenting and Codi... Read more
You Be the Coder:
Stay Away From This Conscious Sedation Scenario
Question: Our general surgeons want the anesthesiologists to set up a system for rout... Read more
Stay Away From This Conscious Sedation Scenario
Question: Our general surgeons want the anesthesiologists to set up a system for rout... Read more
Reader Questions:
Be Aware of Bilateral Breast Documentation
Question: A provider conducted a fine needle aspiration (FNA) biopsy on both breasts... Read more
Be Aware of Bilateral Breast Documentation
Question: A provider conducted a fine needle aspiration (FNA) biopsy on both breasts... Read more
Reader Questions:
Distinguish NCD From LCD
Question: What's the difference between a national coverage determination (NCD) and... Read more
Distinguish NCD From LCD
Question: What's the difference between a national coverage determination (NCD) and... Read more
Reader Questions:
Lean on E/M Documentation for Services Not Actually Performed
Question: Can we count a provider's efforts to counsel a patient against a test as ev... Read more
Lean on E/M Documentation for Services Not Actually Performed
Question: Can we count a provider's efforts to counsel a patient against a test as ev... Read more
ICD-10-CM Updates:
Prepare for These 2025 General Surgery Dx
Apply these ICD-10-CM coding changes beginning October 1 With nearly 250 new ICD-10-CM co... Read more
Prepare for These 2025 General Surgery Dx
Apply these ICD-10-CM coding changes beginning October 1 With nearly 250 new ICD-10-CM co... Read more
Practice Management:
Use This Guidance to Improve Your Coding Education Process
Check out these tips for more effective clinician communication. Coding education is an ... Read more
Use This Guidance to Improve Your Coding Education Process
Check out these tips for more effective clinician communication. Coding education is an ... Read more
HIPAA:
Examine These 3 Cases, Stay Safe from HIPAA Violations
Avoid the fate of these healthcare entities with solid training and compliance strategies.... Read more
Examine These 3 Cases, Stay Safe from HIPAA Violations
Avoid the fate of these healthcare entities with solid training and compliance strategies.... Read more
Reader Questions:
Know Who’s Responsible for Final Dx
Question: Who is responsible for the final diagnosis used for an office/ outpatient e... Read more
Know Who’s Responsible for Final Dx
Question: Who is responsible for the final diagnosis used for an office/ outpatient e... Read more
Reader Questions:
Familiarize Yourself With Free Sample Best Practices
Question: The doctors in our practice often provide our patients with complimentary ... Read more
Familiarize Yourself With Free Sample Best Practices
Question: The doctors in our practice often provide our patients with complimentary ... Read more
Reader Questions:
Heed This Insight on Documentation Requests for CERT Reviews
Question: Our practice is currently in the middle of a Comprehensive Error Rate Testi... Read more
Heed This Insight on Documentation Requests for CERT Reviews
Question: Our practice is currently in the middle of a Comprehensive Error Rate Testi... Read more
You Be the Coder:
Review What Replacement Tubes Cover
Question: Could you please explain the coding process for percutaneous tube insertion... Read more
Review What Replacement Tubes Cover
Question: Could you please explain the coding process for percutaneous tube insertion... Read more
Coding Quiz:
Test Your Knowledge of Adrenalectomy Coding
Focusing on the type of procedure is a great place to start. It's essential to thoroughly... Read more
Test Your Knowledge of Adrenalectomy Coding
Focusing on the type of procedure is a great place to start. It's essential to thoroughly... Read more
News You Can Use:
Hear From Those Affected by the Change Healthcare Outage
Reinforce your skills with paper-based claims. More than four months have passed since ... Read more
Hear From Those Affected by the Change Healthcare Outage
Reinforce your skills with paper-based claims. More than four months have passed since ... Read more
Telehealth Updates:
Keep Up With These Changes to Post-PHE Telehealth
And get ready for telehealth codes to change again in 2025. During her HEALTHCON 2024 pr... Read more
Keep Up With These Changes to Post-PHE Telehealth
And get ready for telehealth codes to change again in 2025. During her HEALTHCON 2024 pr... Read more
Reader Questions:
Calculate Provider Minutes When Performing Phone Visits
Question: Our general surgeon had a telephone visit with a patient to refill prescri... Read more
Calculate Provider Minutes When Performing Phone Visits
Question: Our general surgeon had a telephone visit with a patient to refill prescri... Read more
Reader Questions:
Acknowledge HIPAA Policies When Emailing Results
Question: Sometimes a client or patient requests emailed medical records. What are th... Read more
Acknowledge HIPAA Policies When Emailing Results
Question: Sometimes a client or patient requests emailed medical records. What are th... Read more
Reader Questions:
Beware of Damaging Disclaimers
Question: One of the physicians at our practice uses dictation software, and the vend... Read more
Beware of Damaging Disclaimers
Question: One of the physicians at our practice uses dictation software, and the vend... Read more
You Be the Coder:
Surgeon’s Work Determines Diagnosis Code
Question: The surgeon took a tissue sample from the esophagus during an esophagogastr... Read more
Surgeon’s Work Determines Diagnosis Code
Question: The surgeon took a tissue sample from the esophagus during an esophagogastr... Read more
Surgical Packages:
Follow These Tips for Separately Billed Service Success
Surgical packages may be a glass half full/glass half empty situation. During his HEALTHC... Read more
Follow These Tips for Separately Billed Service Success
Surgical packages may be a glass half full/glass half empty situation. During his HEALTHC... Read more
Appeals:
Fight for Your Right to Appeal and Win
Insurance companies aren't advocating for your office; that's your job. During her HEALT... Read more
Fight for Your Right to Appeal and Win
Insurance companies aren't advocating for your office; that's your job. During her HEALT... Read more
Practice Management:
Study These Strategies for Setting Up a Solid CDI Process
Understand the benefits of regular self-audits. Comprehensive clinical documentation is t... Read more
Study These Strategies for Setting Up a Solid CDI Process
Understand the benefits of regular self-audits. Comprehensive clinical documentation is t... Read more
Reader Questions:
Define Stable Condition
Question: Is there any difference between a chronic condition and a stable condition,... Read more
Define Stable Condition
Question: Is there any difference between a chronic condition and a stable condition,... Read more
Reader Questions:
Always Remain HIPAA Compliant
Question: One of the physicians in my practice demands we use a sign-in sheet — the... Read more
Always Remain HIPAA Compliant
Question: One of the physicians in my practice demands we use a sign-in sheet — the... Read more
Reader Questions:
Understand What Medicare Won’t Pay Extra For
Question: I thought Medicare does not pay extra for physical status modifiers or qual... Read more
Understand What Medicare Won’t Pay Extra For
Question: I thought Medicare does not pay extra for physical status modifiers or qual... Read more
You Be the Coder:
Code This Excess Skin Removal Procedure
Question: Our surgeon operated on a patient who experienced significant weight loss a... Read more
Code This Excess Skin Removal Procedure
Question: Our surgeon operated on a patient who experienced significant weight loss a... Read more
Colonoscopy Coding:
Master the Many Nuances of Colonoscopy Coding
Plus: Learn the subtle difference between “diagnostic” and “therapeutic.” Colonos... Read more
Master the Many Nuances of Colonoscopy Coding
Plus: Learn the subtle difference between “diagnostic” and “therapeutic.” Colonos... Read more
Healthcon 2024:
Avoid Denials Related to Gender and Sexual Orientation
Capturing patient gender identity information correctly is key. Coding for gender-speci... Read more
Avoid Denials Related to Gender and Sexual Orientation
Capturing patient gender identity information correctly is key. Coding for gender-speci... Read more
Practice Management:
Set Your Remote Staff Up for Success With 3 Tips
Empower your team by connecting with them. Remote work arrangements became the norm durin... Read more
Set Your Remote Staff Up for Success With 3 Tips
Empower your team by connecting with them. Remote work arrangements became the norm durin... Read more
Reader Questions:
Code Enterectomy and Anastamosis Procedures With One Code
Question: A gallstone was found in the middle part of the small intestine, leading to... Read more
Code Enterectomy and Anastamosis Procedures With One Code
Question: A gallstone was found in the middle part of the small intestine, leading to... Read more
Reader Questions:
Code This Complication Correctly
Question: The surgeon carried out a flexible sigmoidoscopy with the initial plan of b... Read more
Code This Complication Correctly
Question: The surgeon carried out a flexible sigmoidoscopy with the initial plan of b... Read more
You Be the Coder:
Understand the Difference Between Modifiers 66 and 62
Question: The general surgeon assisted with a liver transplant procedure as part of a... Read more
Understand the Difference Between Modifiers 66 and 62
Question: The general surgeon assisted with a liver transplant procedure as part of a... Read more
Condition Spotlight:
Avoid Hangups When Coding Hemorrhoids
Location and count are key to correctly coding hemorrhoids. When the surgeon removes one ... Read more
Avoid Hangups When Coding Hemorrhoids
Location and count are key to correctly coding hemorrhoids. When the surgeon removes one ... Read more
E/M Coding:
Follow These 5 Tips to Solidify Your Inpatient Care Coding
Stay on top of the hospital E/M revisions. For the last year, you have been using a rev... Read more
Follow These 5 Tips to Solidify Your Inpatient Care Coding
Stay on top of the hospital E/M revisions. For the last year, you have been using a rev... Read more
Compliance:
Maintain Telehealth Compliance in Your Post-PHE Practice
Vendors under contract are also obligated to adhere to HIPAA rules. Telehealth services ... Read more
Maintain Telehealth Compliance in Your Post-PHE Practice
Vendors under contract are also obligated to adhere to HIPAA rules. Telehealth services ... Read more
Reader Questions:
Code This Complication Dx Correctly
Question: If a patient suffers from an intra- or postoperative complication involving... Read more
Code This Complication Dx Correctly
Question: If a patient suffers from an intra- or postoperative complication involving... Read more
Reader Questions:
Heed Medicare Redetermination Timelines
Question: We're nearing the 120-day limit for submitting a redetermination request t... Read more
Heed Medicare Redetermination Timelines
Question: We're nearing the 120-day limit for submitting a redetermination request t... Read more
You Be the Coder:
Refresh Your Understanding of MUEs
Question: Could you please clarify what “MUE” means and explain how it impacts my... Read more
Refresh Your Understanding of MUEs
Question: Could you please clarify what “MUE” means and explain how it impacts my... Read more
Hernia Coding Review:
Refine Your Hernia Repair Coding With These Scenarios
Hernia location is key to coding claims correctly. Hernia repairs are commonly performed ... Read more
Refine Your Hernia Repair Coding With These Scenarios
Hernia location is key to coding claims correctly. Hernia repairs are commonly performed ... Read more
Medicare Tips:
Sharpen Your Medicare Signature Knowledge
Resolving your questionable signatures prior to claim submission is key. In your general ... Read more
Sharpen Your Medicare Signature Knowledge
Resolving your questionable signatures prior to claim submission is key. In your general ... Read more
Practice Management:
Prepare Your Practice to Support Trans Patients and Staff Members
Embracing and supporting all people in your practice is key. Providing optimal care for ... Read more
Prepare Your Practice to Support Trans Patients and Staff Members
Embracing and supporting all people in your practice is key. Providing optimal care for ... Read more
Reader Questions:
Adhere To This Appendectomy Advice
Question: Our surgeon began a laparoscopic appendectomy for a patient with signs of ... Read more
Adhere To This Appendectomy Advice
Question: Our surgeon began a laparoscopic appendectomy for a patient with signs of ... Read more
Reader Questions:
Grasp These 5 Stages of Contesting Medicare Rejections
Question: I filed a claim for a Part B patient with my Medicare Administrative Contra... Read more
Grasp These 5 Stages of Contesting Medicare Rejections
Question: I filed a claim for a Part B patient with my Medicare Administrative Contra... Read more
Reader Questions:
Discover How To Handle Family History Information
Question: When our surgeons get referrals for procedures, the referring physician som... Read more
Discover How To Handle Family History Information
Question: When our surgeons get referrals for procedures, the referring physician som... Read more
You Be the Coder:
Be Cautious When Adding Urinalysis Code to E/M
Question: For all lab tests performed in the office, our nurse researches the history... Read more
Be Cautious When Adding Urinalysis Code to E/M
Question: For all lab tests performed in the office, our nurse researches the history... Read more
Thyroid Coding:
Clear Up Your Thyroid Procedure Coding Confusion
Paying attention to the practitioner's wording is key to successful claims. When coding t... Read more
Clear Up Your Thyroid Procedure Coding Confusion
Paying attention to the practitioner's wording is key to successful claims. When coding t... Read more
Modifiers:
Understand How to Apply Assistant at Surgery Modifiers
Hint: Do not report modifiers 80 and AS together. As a coder specializing in general sur... Read more
Understand How to Apply Assistant at Surgery Modifiers
Hint: Do not report modifiers 80 and AS together. As a coder specializing in general sur... Read more
Practice Management:
Use These 5 Strategies When Adding Valuable Staff to Your Practice
Implementing these techniques during interviews can lead to financial savings. Are you ... Read more
Use These 5 Strategies When Adding Valuable Staff to Your Practice
Implementing these techniques during interviews can lead to financial savings. Are you ... Read more
Reader Questions:
Cut the Fog of Calculating Anesthesia Charges
Question: Could you clarify the process for determining and documenting charges for ... Read more
Cut the Fog of Calculating Anesthesia Charges
Question: Could you clarify the process for determining and documenting charges for ... Read more
Reader Questions:
Learn This Procedure for Unclaimed Funds
Question: During a review, it came to my attention that our practice inadvertently o... Read more
Learn This Procedure for Unclaimed Funds
Question: During a review, it came to my attention that our practice inadvertently o... Read more
You Be the Coder:
Rely on Lesion Diameter Measurement
Question: A 27-year-old patient who is 40 weeks pregnant presented to the provider to... Read more
Rely on Lesion Diameter Measurement
Question: A 27-year-old patient who is 40 weeks pregnant presented to the provider to... Read more
FAQs:
Keep Abreast of Breast Reconstruction Procedures
Review these FAQs to sharpen your reconstruction coding skills. Even the savviest of code... Read more
Keep Abreast of Breast Reconstruction Procedures
Review these FAQs to sharpen your reconstruction coding skills. Even the savviest of code... Read more
Compliance:
Obtain Understanding of Medicare’s New Regulations
Finally get clarification on Medicare's rules for E/M service encounters. The Centers fo... Read more
Obtain Understanding of Medicare’s New Regulations
Finally get clarification on Medicare's rules for E/M service encounters. The Centers fo... Read more
HIPAA:
Impose Sanction Policies for Wrongdoers, OCR Says
Tip: Make employee training match duties. Stopping a data breach incident and retrieving ... Read more
Impose Sanction Policies for Wrongdoers, OCR Says
Tip: Make employee training match duties. Stopping a data breach incident and retrieving ... Read more
Reader Questions:
Correctly Coding This Polyp May Be a Query Away
Question: I'm uncertain about the right diagnosis code to use for a polyp removal sur... Read more
Correctly Coding This Polyp May Be a Query Away
Question: I'm uncertain about the right diagnosis code to use for a polyp removal sur... Read more
Reader Questions:
Collecting Payment for Complications During Surgery
Question: One of our general surgeons encountered some challenges while attempting to... Read more
Collecting Payment for Complications During Surgery
Question: One of our general surgeons encountered some challenges while attempting to... Read more
Reader Questions:
Protect Your Practice’s Electronic Signatures
Question: In our recent risk evaluation, we discovered that the electronic signatures... Read more
Protect Your Practice’s Electronic Signatures
Question: In our recent risk evaluation, we discovered that the electronic signatures... Read more
You Be the Coder:
Exposing the Trachea May Lead to Overlapping Procedures
Question: Our provider performed a routine planned tracheostomy that includes the fol... Read more
Exposing the Trachea May Lead to Overlapping Procedures
Question: Our provider performed a routine planned tracheostomy that includes the fol... Read more
Complication Coding:
3 Tips Help Focus When and How to Report Bleeding Control
Remember the Medicare rule. When your general surgeon must control bleeding either during... Read more
3 Tips Help Focus When and How to Report Bleeding Control
Remember the Medicare rule. When your general surgeon must control bleeding either during... Read more
Don’t Let the Device Dictate Code Selection
Bleeding control is just one use. You just learned in “Solution 2” of the preceding a... Read more
Bleeding control is just one use. You just learned in “Solution 2” of the preceding a... Read more
ICD-10-CM:
Guide Your Liver Condition Coding to Clean Claims
Focus on presenting Dx. When your surgeon treats a patient with a liver condition, kno... Read more
Guide Your Liver Condition Coding to Clean Claims
Focus on presenting Dx. When your surgeon treats a patient with a liver condition, kno... Read more
Reader Question:
Focus Hernia Coding
Question: I'm confused about how to use the CPT® 2023 codes for anterior abdominal hernia... Read more
Focus Hernia Coding
Question: I'm confused about how to use the CPT® 2023 codes for anterior abdominal hernia... Read more
Reader Question:
Look to Debridement With Sharps
Question: The surgeon treated a patient who evidently had recurring infection at the ... Read more
Look to Debridement With Sharps
Question: The surgeon treated a patient who evidently had recurring infection at the ... Read more
Reader Question:
Clarify HIPAA Terminology
Question: What is the difference between “consent” and “authorization” in the... Read more
Clarify HIPAA Terminology
Question: What is the difference between “consent” and “authorization” in the... Read more
Reader Question:
Let Provider Dictate Risk
Question: How do we know the “risk” involved in an encounter so we can understand... Read more
Let Provider Dictate Risk
Question: How do we know the “risk” involved in an encounter so we can understand... Read more
You Be the Coder:
Code This Re-excision Post Mastectomy
Question: Following a right mastectomy for invasive ductal carcinoma, the patient had... Read more
Code This Re-excision Post Mastectomy
Question: Following a right mastectomy for invasive ductal carcinoma, the patient had... Read more
General Coding:
Count Caregiver Counseling As Distinct Time
Question: Can I report a physician's discussion with an elderly patient's caregiver about ... Read more
Count Caregiver Counseling As Distinct Time
Question: Can I report a physician's discussion with an elderly patient's caregiver about ... Read more
General Coding:
Know Limitations of Coder Privileges
Question: One of the patient records I'm reviewing shows a pretty big discrepancy between ... Read more
Know Limitations of Coder Privileges
Question: One of the patient records I'm reviewing shows a pretty big discrepancy between ... Read more
General Coding:
Find Answers to 8 Basic NCCI Questions
Test yourself: Do you know which category of services aren't covered by NCCI? 1. Que... Read more
Find Answers to 8 Basic NCCI Questions
Test yourself: Do you know which category of services aren't covered by NCCI? 1. Que... Read more
General Surgery Coding:
Attempt This Adjacent Tissue Transfer Case
Question: The surgeon carried out a removal of a basal cell carcinoma, measuring 0.5 ... Read more
Attempt This Adjacent Tissue Transfer Case
Question: The surgeon carried out a removal of a basal cell carcinoma, measuring 0.5 ... Read more
General Surgery Coding:
Determine the Correct Outcome of This Debridement Procedure
Highlight the differences between the wound and procedure to select the right code. When ... Read more
Determine the Correct Outcome of This Debridement Procedure
Highlight the differences between the wound and procedure to select the right code. When ... Read more
General Surgery Coding:
Interpret These Op Notes for ‘Wide Excision’
Question: In the operation report I'm currently coding, the surgeon has characterized... Read more
Interpret These Op Notes for ‘Wide Excision’
Question: In the operation report I'm currently coding, the surgeon has characterized... Read more
General Surgery Coding:
Solve This Cancer Scar Revision
Question: A year after undergoing a mastectomy, the patient returns for a scar revisi... Read more
Solve This Cancer Scar Revision
Question: A year after undergoing a mastectomy, the patient returns for a scar revisi... Read more
General Surgery Coding:
Remove the Confusion From This Occlusion
Question: Our surgeon accessed the occluded femoral vein through a tiny incision at t... Read more
Remove the Confusion From This Occlusion
Question: Our surgeon accessed the occluded femoral vein through a tiny incision at t... Read more
General Surgery Coding:
Check Your Splenectomy Coding Knowledge With These FAQs
Understanding the different procedure types is key to successful claim payment. The splee... Read more
Check Your Splenectomy Coding Knowledge With These FAQs
Understanding the different procedure types is key to successful claim payment. The splee... Read more
General Coding:
Adding Modifier 51 Unnecessarily Could Cost You
Question: We have a coder who frequently applies the 51 modifier to nearly all proced... Read more
Adding Modifier 51 Unnecessarily Could Cost You
Question: We have a coder who frequently applies the 51 modifier to nearly all proced... Read more
General Coding:
Consider Consulting MAC With Your NCCI Inquiries
Question: Who should I reach out to if I have inquiries regarding an appeal for a Nat... Read more
Consider Consulting MAC With Your NCCI Inquiries
Question: Who should I reach out to if I have inquiries regarding an appeal for a Nat... Read more