Question: Our general surgeon performed a revision of a reconstructed breast. The surgeon used a method of injecting fat into the breast while performing a revision of abdominal scars from the donor site. The abdominal scar sites were corrected by [...]
Question: I’m new to radiology coding and I’m having trouble choosing which HCPCS Level II codes to assign for the following contrast information in a procedure note: “A mixture prepared using 0.1 cc Magnevist gadolinium contrast, 10 cc preservative free [...]
Does your claim include a provider statement? Patients who report to the emergency department (ED) for critical care services are in peril; they need immediate medical intervention or things could go very badly for them — and fast. That’s one [...]
Remember the eight components of HPI when you’re looking at documentation. Since the evaluation and management (E/M) updates occurred in 2021 and 2023, the focus on E/M education has shifted from discussing each documentation component to mainly medical decision making [...]
Focus on technique and placement is key. It’s crucial to meticulously review the medical records when your urologist performs catheterization procedures. Details such as the type of catheter used, the reason for the catheterization, and the presence of any complications [...]
Preparing for a range of possibilities is crucial for smart Achilles repair coding. When a patient suffers an Achilles tendon injury, the pain is usually immediate and unyielding. However, the task of coding Achilles tendon services doesn't have to be [...]
Question: I know illegibility has historically been an obstacle to good documentation. My practice uses electronic health records (EHR), but I still sometimes get confused when a provider writes QD versus QOD. Is there an alternative I can recommend so [...]
Question: We are billing Medicare for a chemotherapy infusion. The patient received an infusion of leucovorin mixed with 1000 cc of D5W. My question is this: Is the D5W billable? Is it appropriate to bill J0640 with J7070? AAPC Forum Participant [...]
Question: The patient underwent a radical prostatectomy, and the previous op note stated that my urologist performed urethrovesical anastomosis using a double-armed 3-0 V-lock suture. The bladder neck was sutured with a continuous running stitch, beginning at the posterior aspect and [...]
Question: My urologist performed a cysto, bladder biopsy, fulguration, hydrodistension, and heparin instillation. They then placed the scope in the patient’s bladder without difficulty. The patient had an erythema noted from the right lateral wall to the midline. They performed hydrodistension [...]
