BS&SC
Networker
Finally landed a job as a billing specialist, which I have found does require some tweaking of codes, so that is both good...and a struggle for me. Hard because no one else, to my knowledge, has a CPC, and I tend to come at things more from a coding and medical necessity perspective than a let's-get-paid. Anyway, a couple of days ago, I found a fee ticket billing for an E&M code when the patient was taken into the COLPO room for a colposcopy. I felt pretty confident in not allowing the E&M to be billed due to lack of documentation.
On the same ticket, they coded two separate procedures, one for a bx of the vaginal endometrium and the other for a bx of the vulva. I didn't feel like I could code the vulvular bx because the PROCEDURE section of the report does not state anything about the work done for the vulvular biopsy, just the endometrial bx. However, in the FINDINGS section, it mentions the bx of the endometrium and the biopsy of the vulva. Should I allow the CPT code for the reimbursement of the vulva bx despite lack of support for it in the PROCEDURE section? Then, today, after reviewing this again, we discovered that the path for the vulvular biopsy was canceled.
This probably should be pretty straight forward, but as the newbie, I find myself constantly questioning my "training."
On the same ticket, they coded two separate procedures, one for a bx of the vaginal endometrium and the other for a bx of the vulva. I didn't feel like I could code the vulvular bx because the PROCEDURE section of the report does not state anything about the work done for the vulvular biopsy, just the endometrial bx. However, in the FINDINGS section, it mentions the bx of the endometrium and the biopsy of the vulva. Should I allow the CPT code for the reimbursement of the vulva bx despite lack of support for it in the PROCEDURE section? Then, today, after reviewing this again, we discovered that the path for the vulvular biopsy was canceled.
This probably should be pretty straight forward, but as the newbie, I find myself constantly questioning my "training."