surgery

  1. A

    Wiki Lymph Node Biopsy

    My Op note reads as bilateral pelvic lymph node biopsy was performed (documentation does support this). The specimen section also reads RT and LT Sentinel Lymph nodes. The pathology report reads specimen searched and no lymph nodes identified. Can the provider still bill 38570- Laparoscopy...
  2. C

    Wiki Endoscopic Expanded Endonasal Approach for resection of sellar/suprasellar tumor

    I am a Pro-fee neuro e/m coder that is being asked to code a surgery since our outsourced billing/coding company is late to get to it. Dr. F and Dr. T are not with our practice. I'm thinking this should just be 62165-62, but let me know your thoughts as I haven't really touched surgeries that...
  3. S

    Wiki Hysterectomy & Myomectomy

    I am far from an expert and actually very new to OBGYN specialty. I have a surgery that I am unsure of which CPT codes are appropriate and any advice would be appreciated. Case: Pre-procedure diagnosis: 1. Abnormal uterine bleeding 2. Dysmenorrhea 3. Uterine fibroids 4. Pelvic pain...
    • SDELOSSANTOS1
    • Thread
    • coding gyn hysterectomy obgyn obgyn coding surgery
    • Replies: 5
    • Forum: OB/GYN
  4. T

    Wiki Chest Wall Mass Removal

    I am trying to get the correct CPT code for the attached surgery. The office gave me 21601 and I don't believe that is correct because no bone was removed. Can someone please help? Post- Procedure Diagnosis: Post-Op Diagnosis Codes: * Ductal carcinoma of right breast [C50.911] Procedures...
  5. R

    Wiki DENIAL FOR CPT 59151

    hello everyone. I wanted to see if anyone can give me some insight on this surgery. I coded it as a 59151 with icd 10 code o00.101. blue cross denied the claim, stating that the cpt code is not covered with icd 10. If anyone can let me know if the code I used is not correct please let me know. I...
    • rockylopez
    • Thread
    • 59151 ectopic pregnancy laparoscopic surgery
    • Replies: 2
    • Forum: OB/GYN
  6. C

    Wiki Diagnostic and Procedure coding

    If a diagnostic knee arthroscopy procedure was completed but the provider, then also completed a arthroscopy meniscus repair. Would you code both the diagnostic arthroscopy and the repair?
  7. M

    Wiki Intraoperative ultrasound coding

    Hello! This question is related to intraoperative radiologic guidance in surgery. I work in neurosurgery where we do craniotomies/craniectomies, spinal decompressions/fusions, shunts, etc. We typically code for microscopes 69990 and/or stealth navigation 61781 along with procedures. Recently...
  8. R

    Wiki Neurosurgery coding question?

    Hi I am new to neurosurgery and i wanted to reach out to anyone that can help me code this surgery please. Patient had: -removal of right C2-T2 posterior instrumentation -New occipital to T2 right sided instrumentation -New Occiput instrumentation -Occipital to C3 arthodesis. Please if anyone...
  9. G

    Wiki E/M level

    Our surgeon wants a 99205/99215 for these visits. We cannot seem to find the documentation supporting these levels. Wondering if maybe we are missing something? We are also asking so we can have information from somewhere besides us (coders) to support our decision when trying to educate the...
  10. B

    Wiki Assistant surgeon billing

    Hello, I would really appreciate if someone can help me out with billing for an assistant surgeon. I have just started working for a plastic surgeon and he has decided to use an assistant surgeon in one of his surgeries for breast reduction. I would like to know if we have to use different codes...
    • bkhattak
    • Thread
    • assistant surgeon billing modifier 80 modifier as plastic surgery plastic surgery coding surgery surgery center
    • Replies: 20
    • Forum: Billing/Reimbursement
  11. L

    Wiki Orthopedic Surgical Coder (Certified)

    Coding since 2018. Looking for part time or contract work coding trauma, other orthopedic surgeries, or office visits. Please email certworkbiz@gmail.com for inquiries
  12. L

    Wiki Authorization Denials, Surgery

    Curious- Has anyone had surgery auth denials for final coding not being what was anticipated and auth'd prior to surgery that they've appealed successfully? Example: Surgery paperwork may states "Knee arthroscopy, diagnostic, meniscectomy" CPTs: 29870, 29881 called on/submitted for surgery...
  13. L

    Wiki Surgery Auths

    Curious- Has anyone had surgery auth denials for final coding not being what was anticipated and auth'd prior to surgery that they've appealed successfully? Example: Surgery paperwork may states "Knee arthroscopy, diagnostic, meniscectomy" CPTs: 29870, 29881 called on/submitted for surgery...
    • LaurenBrooke
    • Thread
    • appeals authorization billing pre-authorization surgery surgery prior auths
    • Replies: 9
    • Forum: Orthopaedics
  14. M

    Wiki Laparoscopy

    I'm unsure how to code this surgery it was a Operative Laparoscopy with fulguration with endometrial implants. Any ideas?
  15. L

    Wiki Extensor Retinaculum Lengthening

    Provider performed lengthening of the extensor retinaculum overlying the fourth dorsal compartment following excision of extensor tendon intrasubstance ganglion cyst from dorsal hand. Although the cyst had been addressed, it was felt appropriate to slightly lengthen the extensor retinaculum...
    • LaurenBrooke
    • Thread
    • hand ligament lengthening ortho specialty coding retinaculum surgery wrist
    • Replies: 1
    • Forum: Orthopaedics
  16. K

    Wiki IV billing in an Office setting

    Hi all! My office does surgeries from POS 11, we are not surgery center. Can we bill for the IV for fluids and/or drugs that are being adminstered? Thanks in advance! Kim
  17. D

    Wiki Pilon vs Trimalleolar Fx

    Good morning! I need some help in deciding if this is a Pilon Fx-27828- and ankle dislocation with IF-27848- (per what the doctor is requesting) or if this should be coded as a trimalleolar ORIF. I've gone back and forth with this any help or advice will be appreciate....below is the OP note...
    • dcallaway
    • Thread
    • ankle foot and ankle orthopaedic orthopaedics orthopeadic podiatrist podiatry podiatry surgery surgery surgery coder
    • Replies: 1
    • Forum: Orthopaedics
  18. R

    Wiki When to use GC modifier in Surgery

    A coworker and I are trying to discover if there is any rule/policy related to when to use the GC modifier in surgery. Specifically, do you use GC when the resident only observed the surgery or must they participate? The physician is still teaching, but we are not sure the presence of the...
  19. M

    Wiki Please help- Mitral valve repair converted to Mitral valve replacement (33430 & 33425)

    Hi all, How would you code a MEDI-CAL claim for a Mitral valve repair that was converted to a Mitral valve replacement? I just wanted to know which of the two would be primary and the correct modifiers to append. Thank you! :) 33430-AG, 22 33425-51,52,59 OR 33425-AG,52 33430-22,51,59
  20. M

    Wiki Please help on FAST Scans (76705 & 76775)

    We are running into a bit of a confusion at work regarding the FAST scans for the following -76705: Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) -76775: Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image...
  21. C

    Wiki Two Assistant Surgeons

    We have a physician who will soon begin operating with two assistant surgeons on hand and, in certain instances, we will be billing for them both for the same operative session. Their charges will both be billed with an 'AS' modifier due to credentials (PA/CRNP) for the same date and on separate...
    • clark.amy86
    • Thread
    • assistant surgeon modifier as surgery two providers
    • Replies: 2
    • Forum: Orthopaedics
  22. C

    Wiki Two Assistant Surgeons

    We have a physician who will soon begin operating with two assistant surgeons on hand and, in certain instances, we will be billing for them both for the same operative session. Their charges will both be billed with an 'AS' modifier due to credentials (PA/CRNP) for the same date and on separate...
  23. E

    Wiki Can we bill a consult?

    Hello! The patient presented to the ED for pain. The ED physician called our hospitalist, who by the phone recommended a diagnostic laparoscopy for possible ectopic pregnancy. The ED physician documents the patient is discharged to surgery at 1:00 PM. Our hospitalist documents her H&P at 2:45...
  24. J

    Wiki Fracture Manipulation and Surgery

    we had a patient with a displaced distal phalanx fracture which was manipulated in the office and then scheduled for surgery for the next week. can we bill for the manipulation or just the ov/xr/splinting?
  25. S

    Wiki X-ray billing help!

    I'm new to an ASC facility and when it comes to x-rays (almost always performed along with a surgery), I am told that we code professionally with -26 modifier but don't bill at all for the facility side. It was explained to me that x-rays are included in the global surgery package for...
  26. K

    Wiki Mohs

    Hi - I work for a Dermatology Practice. Our Mohs surgeon performed Mohs on a patient's ear. The surgery had a total of 8 stages. I billed 17311 at 1 unit Then 17312 at 7 units I'm pretty sure only 6 units are allowed for 17312, but how do I account for the 8th stage on the claim? Please...
  27. C

    Wiki Office Based Procedure Billing

    I work with a surgeon who has started doing minor surgical procedures in his office, some of which require an anesthesiologist. I am trying to verify if the anesthesiologist can bill insurance separately for these, or if the fee that the surgeon receives is all inclusive, in which case he would...
    • CarlyMae
    • Thread
    • based office office based procedure surgery
    • Replies: 1
    • Forum: Anesthesia
  28. H

    Wiki subsequent orthopedic inpatient visits, i. 99231, 99232

    I am an orthopedic coder needing some clarification. A patient is initially seen in the ED with a femoral neck fracture and the ED provider is requesting Ortho consultation; a hospitalist accepts them as an admit. The Ortho provider consults and determines that the patient needs to be taken to...
  29. L

    Wiki Lap vs Open partial colectomy

    The surgeon feels this partial colectomy with anastomosis should be coded as a laparoscopic procedure, but I think it should be coded as an open one. Just curious what any one else would think & why. Thanks! "After the induction of general anesthesia, the abdomen was sterilely prepped and...
    • lepullem
    • Thread
    • colectomy laparoscopic surgery open surgery surgery
    • Replies: 0
    • Forum: General Surgery
  30. A

    Wiki Resident Surgery

    Hello All! Looking for help clarifying surgical assist involving residents. I'm not 100% comfortable and therefore I keep doubting and confusing myself. First off, if a resident is the first assistant, I understand we can not bill for there service but would it be necessary to add a GC...
  31. J

    Wiki Surgery Coding Help

    Can someone help me code for this procedure please thank you! PROCEDURE PERFORMED: 1. Re-exploration of lumbar wound. 2. Utilization of intraoperative fluoroscopic imaging. 3. Removal of L4-5 transforaminal lumbar interbody fusion spacer. 4. L4-S1 posterolateral autologous lumbar fusion...
  32. B

    Wiki AS/UD Modifier

    New to PA billing for assisting in surgeries. Have done some research, but found contradicting answers. I bill physician billing, not facility billing. 1st Question: Difference in AS and 80 modifiers? I see the definitions in the CPT book, but a few examples may make these make a little more...
  33. C

    Wiki Decision for SX & Pre-Op Clearance Same Day?

    Hi all, I need some help directing an ortho practice I work with. They have been billing 2 E/M codes per day; 1. the PT sees the physician who makes a decision for surgery and bills an E/M code with modifier 57 2. the PT sees an NP within the practice, who bills for a "medical clearance"...
  34. daedolos

    Wiki Pain management during global period for shoulder arthroscopy

    Can I code for an injection to a shoulder site non specific to a shoulder arthroscopy during the global period? Is there any way to unbundle this? Please advise. Peace ?_?
  35. M

    Wiki General Ortho Surgery Charge Posting

    Hello all, I have recently made the move from a pediatrics office to a Pediatrics Orthopedics specialist and while I am familiar with office visits, post-op visits, xrays, & casting. I have NO experience with surgery charges and DME billing. Currently someone else is billing all of our...
  36. L

    Wiki Spinal Hardware Removal

    If the surgeon removes fusion hardware at the L4(locking cap, portion of rod, tulip head, and pedicle screw) in a patient with a history of fusion L4 - S1 can we code 22830 for Exploration of Fusion? During the procedure, the surgeon states "The fusion bed at this level appeared to be robust...
  37. L

    Wiki Lateral Canthotomy Question

    This was a trauma patient. The procedure states it was done for elevated pressure, proptosis, and decreased vision. "Lateral canthus of left eye was cleansed and anesthetized with ...Iris scissors were utilized to cut the skin laterally. I then turned my attention to the inferior crus of the...
  38. L

    Wiki Partially inverted uterus with delivery

    This is a new one for me. I'm not sure if I can code anything extra for the Dr. that delivered, but seems I should be able to bill something for the Dr. that came in and assisted with replacening the uterus. I would appreciate any suggestions for coding this. It was not a package, so I will be...
  39. R

    Wiki Urgently looking for 10 Medical coders for Onsite and Remote coding positions

    Looking For Remote coders for Auditing Physicians Charts. Willing to travel when necessary. • Surgical oncology coder/Auditor for physician services with E&M coding. • Radiation oncology coder for physician services with E&M coding. Responsibilities: • Surgical coder with oncology experience...
  40. M

    Wiki Global Period Question

    Hello, If a resident or a fellow (non-billable) from Urology performs a major surgery (90 day global period), can the following days (subsequent visits) be billed by the Urology Attending physician since the Attending did not perform the surgery? Please advise. Thanks, Mary V., RHIA, CPMA
  41. J

    Wiki Certified Coders Needed at Wichita Surgical Specialists

    Coder needed, CPC or RHIT. Full-time, Monday-Friday, 8am to 5pm, busy surgical practice. Coding experience preferred. Communication, computer & organizational skills necessary. Excellent benefit package. Apply online at: www.wsspa.com/careers EOE/Vets/disabled/M/F/Federal Contractor.
  42. S

    Wiki level of risk

    Could I get some opinions please? Note says: Surgical procedure for resection of plantar calcaneal spur is explained to her in detail.* Surgery is not recommended as of yet. Does anyone else think that the "surgery is NOT recommended" part cancels out the Moderate level of risk that would be...
    • solocoder
    • Thread
    • level moderate recommended risk surgery
    • Replies: 1
    • Forum: E/M
  43. A

    Wiki Trigger Point at Bedside

    Patient was supposed to go to surgery for a lipoma removal and a shoulder trigger point injection. The patient never made it to surgery and while in holding they did the trigger point injection. I know we cannot charge OR charges but can we still charge for the injection?
  44. S

    Wiki ASC Billings/ Coding

    Our surgery center bills for the ASC Facility fee and we have an Orthopedic surgeon who wants to do a 29827 (arthroscopic rotator cuff repair) and then have a Pain Management physician come into the OR and do a 64483 (lumbar transforaminal epidural) on the same patient, for a completely separate...
  45. S

    Wiki ASC Billing/ Coding

    Our surgery center bills for the ASC Facility fee and we have an Orthopedic surgeon who wants to do a 29827 (arthroscopic rotator cuff repair) and then have a Pain Management physician come into the OR and do a 64483 (lumbar transforaminal epidural) on the same patient, for a completely separate...
    • sienamt
    • Thread
    • asc coding epidural lumbar surgery
    • Replies: 1
    • Forum: Orthopaedics
  46. S

    Wiki Surgery Assist non payable procedures

    Where can I get a list of all procedures that aren't AS payable? TIA Sharon, CPC General Surgery and Hospitalist
  47. D

    Wiki HELP is there a Code for large group Refractive surgery seminar

    We have a physician who performs Lasik PRK surgeries. Once a month the have a seminar for all the West Point Cadets interested in the surgery, anywhere from 30-200 cadets attend the 60 minute seminar for refractive surgery options. Counceling covered multiple areas, to include purpose of...
  48. M

    Wiki Global Denial - out of sequence dates of service

    We have a claim that denied as being included in the global period of another procedure, however this was the first surgery we had performed on this patient. When I called Cahaba I was told the claim was billed out of sequence with a subsequent procedure performed 2 weeks after the first...
  49. P

    Wiki Bariatric surgery - lap band deflation

    Is there a CPT for this or would this be included in the office/clinic visit? AP standard band deflated Numbing spray used Port cleaned with alcohol Huber needle used to access port 7 ml of saline removed from band
  50. D

    Wiki How to code Medicare Preop evaluation

    What code should I use for a Preop evaluation for a patient that is going for cataract surgery and has Medicare for insurance? I use as first diagnosis Z01.818 and was denied. Do I have to use the Z code as a second diagnosis and code the reason of the surgery first?
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