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Neurosurgery Coding Alert

CPT® Coding:
A Look Back at 2021: E/Ms, Midyear Additions Highlight 2021 Changes
Check out the codes that CPT® dropped mid-July. By all accounts, 2021 was an action-pack... Read more
CPT® Coding:
Get Hip to What’s Coming in 2022 and Beyond
E/M section will be further altered in coming years. The last couple of years have seen m... Read more
Reader Questions:
Get all Info Before Diving Into E/M-CT Combo Encounter
Question: Notes indicate the provider performed an office evaluation and management ... Read more
Reader Questions:
Rely on Add-On for Second Hemilaminectomy
Question: Encounter notes indicate that the surgeon performed a hemilaminectomy at C1... Read more
Reader Questions:
Keep Up With 99211 Reporting Rules
Question: What are the minimum documentation requirements needed to bill 99211? What ... Read more
Reader Questions:
Drive Dx Decision With Provider Documentation
Question: One of our patients is a former opioid addict, and I am not sure what ICD-10 cod... Read more
Reader Questions:
Don’t Code Conditions Before They Happen
Question: Please settle this debate. One of our providers is saying that we should a... Read more
Reader Questions:
Use G43.6 for Various Syndrome Dxs
Question: Notes indicate that a patient suffered from Wallenberg syndrome. I'm not fa... Read more
Reader Questions:
Calculate MDM Risk for This Encounter
Question: Our provider recently spent some time discussing the risk factors for major... Read more
You Be the Coder:
Difficult Terminology in Op Notes
Question: Encounter notes indicate that the surgeon performed “DREZ laminectomy, thoraco... Read more
2022 E/M Coding:
CPT® Brings 99211 in Line With Other Office E/Ms
Here's the minor descriptor change that could have a major effect on coding. When CPT® r... Read more
CPT® Coding:
Set Up for Spinal Stenosis Success With Code Knowledge
Provider could use several methods to determine presence of condition. Patients reporting... Read more
E/M Coding:
Use Keen Eye, Coding Smarts to Tackle Observation Coding
Remember different codes for different payers, types of stays. Reporting observation se... Read more
Reader Questions:
Questions Persist on New Back Pain Codes
Question: How do I code acute or chronic lower back pain? Even with the new ICD-10 codes i... Read more
Reader Questions:
Get an Accurate Count of Nerve Conduction Tests
Question: Notes indicate that the provider performed sensory nerve conduction test using e... Read more
Reader Questions:
Px Status Crucial to E/M Code Choice
Question: Notes indicate that the provider performed an office evaluation and managem... Read more
Reader Questions:
Tumor Type Drives Craniectomy Code Choice
Question: What is the correct code for infratentorial craniectomy to excise a brain t... Read more
You Be the Coder:
Spinal X-Rays in 2 Areas
Question: Encounter notes indicate that the provider performed X-rays on two areas of a pa... Read more
CPT® 2022:
Get Up to Speed on New LITT, Laminectomy Codes
A new lesion therapy gets its own code in 2022 … and a lot more. Many years, the announ... Read more
CPT® 2022:
Revisions Revved Up for Next Year
Here's why you need to pay special attention to 2022 code revisions. When it rains, it... Read more
Modifier Madness:
Code Unrelated E/Ms With 24 … When Possible
Instead of relying on your clinic schedule for documentation proof, do this. Knowing the ... Read more
Reader Questions:
Use This Advice on High-Level Drug Therapy E/Ms
Question: What qualifies as “drug therapy requiring monitoring” in the high-risk ... Read more
Reader Questions:
Use Observation Codes for More Than Primary Dx
Question: Should we report the observation diagnosis codes (Z03-Z05) as primary diagnoses ... Read more
Reader Questions:
Knowing Circumstances Surrounding ECoG Vital to Code Choice
Question: When the surgeon performs an electrocorticogram (ECoG), how should I report the ... Read more
You Be the Coder:
MDM Coding: 1 Bullet or 2?
Question: I am still getting used to the new rules for office/outpatient evaluation and m... Read more
ICD-10- 2022:
See What ICD-10 2022 Will Look Like With New Codes
There will be a whole new set under the S06.0 heading. Don't be alarmed, but you're about... Read more
E/M Coding:
Catch Up With Still-Evolving Office/Outpatient E/M Rules
Here's why you should keep a lookout for more tweaks to rules. Autumn is almost upon us, ... Read more
Modifier Madness:
Prove Separate and Distinct Before Opting for Modifier 59
… and some payers might prefer the X{EPSU} modifier options. Payers never stop scrutini... Read more
Reader Questions:
Count Sutures, Then Choose Newborn Craniectomy Code
Question: Encounter notes indicate that the surgeon performed a craniectomy for craniosyno... Read more
Reader Questions:
Vascular Territory Important on Balloon Dilatations
Question: Encounter notes indicate that the surgeon performed three intracranial balloon d... Read more
Reader Questions:
Use Unlisted Code When Others Don’t Describe Procedure
Question: I've reported CPT® code 64999 for an erector spinae pain (ESP) block for years,... Read more
You Be the Coder:
Meet Threshold on New Prolonged Services Code
Question: Our provider performed an office evaluation and management (E/M) service for a n... Read more
ICD-10- 2022:
Dx Additions Include Expanded Options for Concussion, Back Pain
Here's why you should learn the new codes before the end of summer. When the calendar fli... Read more
E/M Coding:
Keep Up ED E/M Skills in 2021
These codes don't have the updated descriptors of 99202-99215. When your surgeon provides... Read more
Clinical Coding Corner:
Get Back to Basics on Disc Disorder Claims
Scenario illustrates the intricacies of cervical disorder treatments. Patients who have c... Read more
Reader Questions:
Table E/M Risk Concerns With MDM Smarts
Question: Both the Elements of Medical Decision Making (MDM) table in the 2021 CPT®&... Read more
Reader Questions:
Study Different Types of TIA Dx Codes
Question: I'm still pretty new to neurosurgery coding, and I'm curious about the different... Read more
Reader Questions:
Make the Most Correct Choice on E/M Level
Question: Notes indicate that the provider performed an office evaluation and managem... Read more
You Be the Coder:
Get Modifier Right on 2-Sided Surgeries
Question: Our neurosurgeon created a subdural burr hole in order to drain a hematoma.... Read more
Case Study Corner:
Use These Modifiers to Code Second Surgeries Successfully
Use 58 for a planned or staged procedure. Last month, we ran down the modifiers you shou... Read more
Studies:
Know Code Combos to Dodge EMG/NCS Coding Troubles
Do you know which NCS code you'll report with EMG of extremity? Patients reporting to you... Read more
Back to Basics:
Use Injection/Infusion Advice to Be a Hotshot Coder
Read this if you ever get confused about proper injection/infusion types. Coding for inje... Read more
Reader Questions:
Dig Deep for Answers to Craniotomy Questions
Question: After a level five outpatient evaluation and management (E/M) service for an est... Read more
Reader Questions:
Know Clamp Types to Lock Down on Aneurysm Repair Coding
Question: The surgeon performed surgery on an intracranial aneurysm via cervical approach.... Read more
Reader Questions:
Report Prolonged Services With Telehealth E/M … Maybe
Question: Our provider performed an office evaluation and management (E/M) service over th... Read more
You Be the Coder:
Reporting Multiple TFESI Injections
Question: The physician documented transforaminal epidural steroid injections (TFESI) at l... Read more
2021 E/M Q&A:
New Reporting Rules Have Early Hits, Misses
Focusing on MDM has changed the calculus for coders, providers. When the AMA decided that... Read more
Surgery:
Head Down the Right Coding Path With Craniotomy/Craniectomy Skills
Use add-on code when surgeon removes skull portion. When your surgeon performs a craniot... Read more
Modifier Madness:
Get 58/76/78/79 Rules Straight Before Coding Surgery During Global
Do you know which modifier to use if the surgery is related to a previous procedure? Codi... Read more
Reader Questions:
Multiple Brachial Plexus Blocks = 1 Code
Question: The provider administered a brachial plexus block. He wants to bill this with 8 ... Read more
Reader Questions:
Get Back to Spinal Compression Fx Basics
Question: I'm a little unclear on spinal compression fractures. What exactly are they, and... Read more
Reader Questions:
Skull Base Lesion Tx Requires Multiple Surgeons
Question: When a patient receives treatment for a skull base lesion, how many differe... Read more
You Be the Coder:
Add-Ons and Vertebral Surgery Codes
Question: Our surgeon performed percutaneous lumbosacral vertebroplasty with biopsy, which... Read more
ICD-10 Coding:
Account for Secondary Conditions for Spinal Patients
Myelopathy, radiculopathy among conditions that can accompany primary issue. When a pati... Read more
E/M Coding:
2021 E/M Changes Get Some … Changes
Recent updates shed more light on the 2021 office/outpatient E/M revisions. If you missed... Read more
E/M Coding:
Keep Hospital Care Codes in Their Own Category
Use 1 set of codes for initial hospital care. There's been a ton of attention paid to the... Read more
Reader Questions:
Know When to Say When With Modifiers
Question: Encounter notes indicate that the neurosurgeon created a burr hole to implant el... Read more
Reader Questions:
Visualize Success by Mastering Spinal Cord Vocab
Question: I'm having trouble with some of the terminology when coding injection/drainage/a... Read more
Reader Questions:
Know HIPAA Rules Before Sending Patients Email
Question: Our patients frequently ask if we can send them appointment reminders or bills v... Read more
You Be the Coder:
Try to Get More Info on ‘Trigem. Nerve Disorder’ Note
Question: I have an operative report in front of me that is a bit confusing. Notes indicat... Read more
CPT®:
Here’s Why Time and Set Up Matter When Reporting Continuous EEG/VEEG Services
Hint: Report 95700 only once per recording period. You may be stumped if your physician r... Read more
ICD-10-CM:
5 Tips Hone Your Sciatica ICD-10-CM Reporting Skills
Remember: You must know the sciatica's exact location. When it comes to reporting ICD-10-... Read more
Modifiers:
Append Assistant Surgery Modifiers With Ease Using This Handy Guide
An indicator of “1” tells you that an assistant at surgery will never be paid. When y... Read more
You Be the Coder:
Look to Global for Modifier Success
Question: Notes indicate that after a level-four outpatient E/M service for an established... Read more
Reader Questions:
Report These S- ICD-10-CM Codes for Neck Sprain
Question: My surgeon treated a patient complaining of neck pain. The encounter notes indic... Read more
Reader Questions:
Distinguish Between EMRs and EHRs
Question: At our practice, we often use the terms EMR and EHR interchangeably, but our new... Read more
Reader Questions:
Bolster ABN Smarts With These Steps
Question: I'm new to coding. Can you please explain to me what an advance beneficiary not... Read more
CERT:
Medical Necessity Errors Result in Over $85 Million Projected Improper Payments for Neurosurgery, Per CERT Report
Cervical spinal fusion lands at the top of costliest medical necessity mistakes. You know... Read more
CPT®:
4 Tips Help Conquer Myelography Coding in Your Neurosurgery Practice
Hint: Check the documentation for the exact approach. If your neurosurgeon performs myel... Read more
Mythbuster:
Bust 5 Modifier 62 Myths to Solidify Your Claims
Make sure the ICD-10-CM codes match on both physicians' claims. A new subscriber recent... Read more
You Be the Coder:
Demystify This Fracture Repair Situation
Question: My physician performed closed treatment of a fracture of a vertebral process in ... Read more
Reader Questions:
Make Sure Your Mobile Devices Meet HIPAA Requirements
Question: How can we help secure our mobile devices, meet HIPAA requirements, and help saf... Read more
Reader Questions:
Approach Key for Pituitary Tumor Excision
Question: My neurosurgeon made an incision in the patient's scalp above the frontal area o... Read more
Reader Questions:
Decode What Medical Necessity Means
Question: I know medical necessity is vital to coding, but I'm not sure that I can define ... Read more
CPT®:
Sharpen Your Ventriculoperitoneal Shunt Tap Coding Skills With This Expert Advice
Remember: Don't mix up shunt tap with shunt irrigation. When your neurosurgeon performs a... Read more
Quiz:
7 Questions Guide Your Coding for Malignant Tumors in the Spinal Cord and Cauda Equina
Report C72.59 for malignant tumor in the Trochlear cranial nerve (IV). If you neurosurge... Read more
Policy:
Determine COVID-19 Vaccination Policy For Your Practice
Considering modeling your COVID-19 policy after your flu policy. Now that a COVID-19 vac... Read more
Reader Questions:
Follow This Advice for Medicare Appeals, Rebuttals
Question: Our practice just received a “demand letter” from our Medicare Administrativ... Read more
Reader Questions:
Conduct Self-Audit to Confirm Correct Medicare FFS Reimbursement
Question: What are some areas my office can perform a self-audit on or otherwise focu... Read more
Reader Questions:
Rely on This Code for Ankylosing Spondylitis of the Thoracic Region
Question: Which ICD-10-CM code should I report for ankylosing spondylitis of the thoracic ... Read more
Reader Questions:
Focus on Dx Code for Vascular Dementia Without Behavioral Disturbance
Question: Which ICD-10-CM code should I report for vascular dementia without behavioral di... Read more
You Be the Coder:
Focus on Number of Treatment Days for Adhesiolysis
Question: My neurosurgeon performed an epidural lysis of adhesions using hypertonic saline... Read more
CPT®:
Differentiate from Implantation, Revision, and Removal Spinal Stimulator Codes to Achieve Cleaner Claims
Remember: Never report 95971 in conjunction with 95972. If your neurosurgeon performs a s... Read more
HCPCS Level II 2021:
2021 HCPCS Level II Welcomes New Clinical Indications for Head Imaging Codes
Hint: Code G9532 will be deleted in 2021. The Centers for Medicare & Medicaid Servic... Read more
Queries:
Always Submit Successful Provider Queries in Your Neurosurgery Practice
Remember: A query should never be used to question a provider's clinical judgement. Dur... Read more
You Be the Coder:
Use Modifier 22 With Caution
Question: My neurosurgeon planned to remove a patient's intraventricular colloid cyst usin... Read more
Reader Questions:
Learn How to Protect e-Signatures
Question: During a recent risk assessment at our practice, we found that the e-signatures ... Read more
Reader Questions:
Follow This Cranial Neurostimulator Removal Advice
Question: My neurosurgeon re-incised the skin over a direct cranial pulse generator in a s... Read more
Reader Questions:
File Claims With Care
Question: If we received an “unprocessable” claim from our MAC, can we appeal this? N... Read more
Reader Questions:
Inspect Cranioplasty Details in Medical Documentation
Question: My neurosurgeon repaired a 4cm skull bone defect by using bone tissue harvested ... Read more
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