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E/M + Bronchoscopy + PFT: Unlock the Secrets to Signs and Symptoms Coding

Keep your CCI edits in mind for PFT bundles.

When a patient presents with common respiratory conditions, your pulmonologist should perform an extensive history and examination, and may order several diagnostic tests before he can settle with a definite diagnosis to report in the claim. Along with the primary diagnosis (if achieved), you should report the patient’s signs and symptoms or else risk an audit.

Consider this scenario: The pulmonologist sees a patient for fever, shortness of breath, chest pain, weight loss, and fatigue. After undergoing a detailed history and examination, the patient becomes suspect for hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x). The physician orders a diagnostic bronchoscopy with fluoroscopic guidance, as well as a spirometry to verify the patient’s condition. To justify each service performed by the same provider or group, you might be accumulating payer inquiries or denials. This 2-step technique should carry you through potentially puzzling spirometry-E/M coding situations.

1. Don’t Leave Out Signs and Symptoms On Your Claim

 First on your to-do list is to report the patient’s signs and symptoms. In this case, you would code 780.6 (Fever and other physiologic disturbances of temperature regulation), 786.05 (Shortness of breath), 786.50 (Unspecified chest pain), 783.21 (Loss of weight), and 780.79 (Other malaise and fatigue). Because these signs and symptoms resemble other respiratory problems, the physician performs a level four E/M and orders some diagnostic tests. Report the procedures with: 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) for the bronchoscopy with fluoroscopic guidance. Your physician is likely to perform this on a separate date. 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function test (PFT); and 99214 (Office

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Deem Time Essential for 493.02 Treatment Services

Learn when prolonged services should not apply.

Reporting your pulmonologist’s asthma attack treatments can be crafty business, as you can be confused about what, how and when to choose from the E/M and treatment codes that describe different situations.

Learn a few secrets of the trade from these scenarios:

Scenario 1: A patient suffering from hay fever with exacerbated asthma (493.02, Extrinsic asthma; with [acute exacerbation) requires two nebulizer treatments and 55-minute treatment time. What coding option would you report?

Scenario 2: A child patient with asthma experiences active wheezing and shortness of breath. The patient’s parent brings the child to the office, and demands the physician to see her child right away because the child is restless and screams in pain.

Dodge a Bullet by Putting Modifier 76 in Its Right Place

Some practices would report Scenario 1 using a level four established patient office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) with prolonged services (99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]).

They would think that the 99214 visit would include 25 minutes of face-to-face time, while 99354 would cover the additional 35 minutes. However, this is not correct coding — a common mistake of coders, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. “You cannot report prolonged care to account for monitoring time associated with separately billable procedures (i.e., nebulizer treatments),” she explains….

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Modifier 57 Remains Handy Post Removal of Consult Codes

Take a hint from a CPT®’s global period when choosing between modifiers 25 or 57

Contrary to popular thinking, modifier 57 does not apply exclusively for consultation codes only. Medicare may have stopped paying for consult codes, but this doesn’t mean you have to stop using modifier 57. Here are two tips on how you can use this modifier to suit your practice’s needs.

Background: Starting January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) eliminated consult codes from the Medicare fee schedule.

Non-Consult Inpatient Codes Keep Modifier 57 Alive

With CMS eliminated consult codes (99241-99245, 99251- 99255) for Medicare patients, you might have wondered if modifier 57 (Decision for surgery) would remain useful. The answer? You can still use this modifier for a non-consult inpatient E/M code, so long as your documentation supports it. This is because any major procedure includes E/M services the day before and the day of the procedure in the global period, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “The only way you can be paid properly for an E/M performed the day before the major surgery or the day of the surgery is to indicate that it was a decision for surgery (modifier 57), which also indicates to the payer that the major procedure was not a pre-scheduled service,” she explains.

Past: Say the pulmonologist carries out a level four inpatient consult in which she figures out the patient requires thoracoscopy with pleurodesis for his recurring, persistent pleural effusion (511.9). The physician decides to perform thoracoscopy with pleurodesis the day after the consult. In this case, appending modifier 57 to the E/M code (99254, Inpatient consultation for a new or established patient, which requires these 3

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CMS Offers Great News With Fee Schedule Changes

Boost co-surgery, multiple surgery, and bilateral surgery pay for these select procedures

You’ll no longer have to eat the cost of your services if your physician acts as co-surgeon on spine revisions. Thanks to several Fee Schedule changes that CMS recently enacted. CMS had good news in MLN Matters article MM7430, which had an effective date of Jan. 1, 2011 and an implementation date of July 5, 2011.

Look for Potential Co-Surgery Payment for These Codes:

CMS will change the co-surgery indicator for spine revision codes 22212 and 22222 from “0” to “1”. Keep in mind that supporting documentation is required when billing for a co-surgeon with these procedures, so don’t forget to submit that with your claim or you’ll be looking at bad news.

Remember: If you’re billing for co-surgery, append modifier 62 (Two surgeons) to your procedure code. For modifier 62 claims, most payers pay an additional fee (generally 125 percent of the “usual” fee for the procedure, split evenly between the two surgeons). Avoid reimbursement problems by checking these claims carefully. To claim co-surgeons, each surgeon must perform a distinct portion of a single CPT procedure, and each surgeon must dictate and submit his own operative report for his portion of the surgery.

Benefit From Surgical Assist Changes:

Practices that perform sinus endoscopies will also get a potential boost from the fee schedule changes, now that you’ll see the assistant at surgery indicator change for codes 31233 and 31235 from “1” (Assistant at surgery may not be paid) to “0” (Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity).

You’ll append modifier 80 to the assistant’s surgical codes if the assisting surgeon is a physician. In cases when a non-physician assists at surgery on Medicare patients, append…

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Qualedix, Inc. Partners with the Coding Institute to Bring Enhanced Quality and Education to its Managed Services Solution for ICD-10 Testing

Naples, FL (June 15, 2011) –Qualedix, an advanced healthcare testing organization, today announced it has partnered with the Coding Institute, LLC, a company dedicated to offering accurate healthcare solutions, that will provide native ICD-10 coding expertise and educational services to the industry leading Simplicedi testing platform.

The combined market offerings enable greater accuracy, speed and a true clinical approach to tackling the arduous task of testing thousands of new ICD-10 codes for providers and payers alike.

“At Qualedix, we strive for excellence in our data solutions for the industry and clinical knowledge is paramount to effectively remediate and test ICD-10 changes across the healthcare industry. The Coding Institute brings to a new echelon of quality and expert knowledge to better effectively serve the market through our testing managed services,” said Mark Lott, CEO of Qualedix. “Also, all of our clients need education to assist in the transition period and we are proud to have TCI as our education and training partner.”

“The Coding Institute is excited about the opportunity to partner with Qualedix to provide unmatched testing and training to help healthcare professionals implement ICD-10 compliantly and efficiently,” said Jennifer Godreau, BA, CPC, CPMA, CPEDC, Director of the SuperCoder.com and Consulting & Revenue Cycle Solutions divisions of the Coding Institute.  “As the healthcare industry’s most advanced ICD-10 testing and education methodology, this managed services solution identifies key areas of focus for hospitals, insurers, and providers and allows us to prevent incorrect coding and revenue losses.”

About Qualedix

Qualedix is a professional healthcare IT quality assurance and software testing firm delivering outsourced managed testing services that leverage our expertise in healthcare and software development lifecycles. Qualedix has developed highly strategic methodologies and techniques designed to deliver critical, cost-effective solutions for 5010 and ICD-10 with highly technical testing experts, healthcare business acumen,…

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CMS Proposes New Glaucoma, Skin Cancer, Dementia Codes

 

Many new codes abound in final update to proposed ICD-9-CM code set

If you’ve felt that your skin cancer diagnoses could use a bit more specificity, ICD-9 will deliver this October if the proposed list of new, deleted, and revised diagnosis codes becomes final. The list of ICD-9 changes was recently posted to the CMS Website, and includes the final full set of changes that the agency will make to ICD-9 codes. After the new codes take effect on Oct. 1, CMS will only add new ICD- 9 codes on an emergency basis as it prepares to switch over the diagnosis coding system to ICD-10.

 

Seek Out Skin Cancer Changes

You’ll find a significant expansion to the 173.x (Other malignant neoplasm of skin) categories, including changes to 173.0x (…Skin of lip), 173.1x (Eyelid, including canthus), 173.2x (Skin of ear and external auditory canal), 173.3x (Skin of other and unspecified parts of face), 173.4x (Scalp and skin of neck), 173.5x (Skin of trunk, except scrotum), 173.6x (Skin of upper limb, including shoulder), 173.7x (Skin of lower limb, including hip), 173.8x (Other specified sites of skin), and 173.9x (Skin, site unspecified).

 Among these changes, for example, you’ll find the following new codes to delineate various types of skin cancers:

  • 173.60 —Unspecified malignant neoplasm of skin of upper limb, including shoulder
  • 173.61 — Basal cell carcinoma of skin of upper limb, including shoulder
  • 173.62 — Squamous cell carcinoma of skin of upper limb, including shoulder
  • 173.69 — Other specified malignant neoplasm of skin of upper limb, including shoulder.

 The changes in the other skin cancer categories referenced above follow this pattern, with the fifth digit of “0” referring to an unspecified malignant neoplasm, “1” denoting a basal cell cancer, “2” referring to a squamous cell carcinoma,” and “9”…

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HPI Know-How Helps You Catch Level 4 and 5 E/M Opportunities

 

Beware of CPT® and Medicare differences when counting HPI elements.

Not accurately accounting for the history of presentillness (HPI) documented by your oncologist could result in missing appropriate opportunities to report level 4 or 5 E/M visits. Ensure you’re not missing higher paying possibilities by reviewing this guide to capturing HPI elements.

Brush Up on What Qualifies as an HPI Element

HPI is one of the three parts comprising an outpatient E/M history. It describes the patient’s present illness or problem, from the first sign/symptom to the current status, and typically drives a provider’s decisions about the physical examination and treatment. “The information gathered during the physical exam (PE) portion of a patient’s evaluation often only shows a very limited picture of the patient’s problem. However, speaking with a patient and gathering the history of the patient’s problem” can help fill out the picture, explains Amanda S. Stoltman, CCS-P, compliance coder at Urology Associates in Muncie, Ind.

 Start counting:

HPI also will often determine the level of service you’ll report. You’ll count the HPI elements to help you determine which level of service you can report. There are seven or eight HPI elements, depending on which source you are following. For Medicare, the eight elements are as follows: 

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms.

Medicare includes the above list in both the 1995 and 1997 E/M Documentation Guidelines, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

In contrast: CPT® lists only seven HPI elements in the E/M Services Guidelines, with duration not making the list. Therefore, for Medicare and payers following its guidelines, you should consider duration and timing separately. With payers that follow AMA rules, however, be aware that they don’t consider duration and timing to be two separate elements. Rumor has it…

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Pick Up on PIN III’s Trail in Index

Question:
I have a path report that says “PIN III.” My problem is that the report also says “carcinoma was not identified,” so I’m confused about what to report. Which ICD-9 code is best?
 Answer:
With a diagnosis of PIN III, you should repo…

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CMS Proposes New Glaucoma, Skin Cancer, Dementia Codes

Many new codes abound in final update to proposed ICD-9-CM code set.

 If you’ve felt that your skin cancer diagnoses could use a bit more specificity, ICD-9 will deliver this October if the proposed list of new, deleted, and revised diagnosis codes becomes final. The list of ICD-9 changes was recently posted to the CMS Website, and includes the final full set of changes that the agency will make to ICD-9 codes. After the new codes take effect on Oct. 1, CMS will only add new ICD- 9 codes on an emergency basis as it prepares to switch over the diagnosis coding system to ICD-10.

Seek Out Skin Cancer Changes

You’ll find a significant expansion to the 173.x (Other malignant neoplasm of skin) categories, including changes to 173.0x (…Skin of lip), 173.1x (Eyelid, including canthus), 173.2x (Skin of ear and external auditory canal), 173.3x (Skin of other and unspecified parts of face), 173.4x (Scalp and skin of neck), 173.5x (Skin of trunk, except scrotum), 173.6x (Skin of upper limb, including shoulder), 173.7x (Skin of lower limb, including hip), 173.8x (Other specified sites of skin), and 173.9x (Skin, site unspecified).

Among these changes, for example, you’ll find the following new codes to delineate various types of skin cancers:

  • 173.60 —Unspecified malignant neoplasm of skin of upper limb, including shoulder
  • 173.61 — Basal cell carcinoma of skin of upper limb, including shoulder
  • 173.62 — Squamous cell carcinoma of skin of upper limb, including shoulder
  • 173.69 — Other specified malignant neoplasm of skin of upper limb, including shoulder.

 The changes in the other skin cancer categories referenced above follow this pattern, with the fifth digit of “0” referring to an unspecified malignant neoplasm, “1” denoting a basal cell cancer, “2” referring to a squamous cell carcinoma,” and “9” describing another…

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Improve Your Tennis Elbow Claims Score: Make Reach, Repair, and Reattachment Your Winning Strategy

Tactics help you recoup deserved pay for 24357-24359.
Tennis elbow claims faults can wreak havoc on your reimbursement for these services.  But you can clean up your method if you can spot in the note how the surgeon reached the elbow tendon and whether the tendon was released or repaired.  By doing so, you stand to gain your full earned pay for codes 24357, 24358, and 24359, which is $437.27, $514.74, and $647.59, respectively.
Review Structures Treated
When you are confident in your elbow anatomy knowledge, you’ll have a better chance of understanding where the operative note is directing you.   The codes are simple and can easily be applied if you are reading correctly. “Coding these procedures became much easier when CPT condensed the codes from the previous five down to the current three,” confirms Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.  The bones, –humerus above and the radius and ulna below– articulate in a manner to allow 180 degrees of movement that helps you use the upper limb for various functions.

The numerous muscles that originate and insert around the joint allow movement; particularly important is the bundle of extensors including the muscle extensor carpi radialis brevis (ECRB) that originates at the lateral epicondyle which is the lateral prominence of the humerus at the elbow joint.  Repeated back movements of the wrist joint, as seen when playing tennis, can cause small micro tears in the tendon of origin and result in inflammation known as lateral epicondylitis or ‘tennis elbow.’ The term is highly deceptive, though; the condition affects non-athletes as well, and is not solely confined to tennis players. As the pathology progresses, the damaged tendon(s) may rupture and…

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Correctly Code Crush Injury of Hand

Question:
We have a patient who had a severe crush injury of the left hand which led to a comminuted fracture of the left 3rd and 5th metacarpals with an intra-articular fracture of the proximal phalanx of the left index finger.  The physician’s documentation indicates the following:

  • There was also a soft tissue defect over the left proximal interphalangeal (PIP) joint of the middle finger.  After taking samples for culture, the wounds were meticulously débrided and curetted.
  • Bony structures were evident over the 3rd metacarpal as well as on the PIP of the middle finger where the defect was about 3-1/2 to 2-1/2 inches. The area of the dorsum of the PIP joint of the left middle finger was about ¾ inch x ¾ inch.
  • Debridement and irrigation was done using 6 liters of saline with the gravity Patzakis technique and 1 liter of antibiotic.
  • After the wound was washed, X-rays were taken to confirm the fractures though no attempt was made to reduce any fractures because of the severe contamination.  A wound-VAC was planned for the dorsum of the left hand at the PIP joint of the left small finger.

Would I report 11043 and 97605 with ICD-9 682.4 and 681.00?

-North Carolina Subscriber

Answer:
The correct codes in this situation would be 11010 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and
subcutaneous tissues), 11011 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle), or 11012 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and…

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Follow 4 Simple Tips for Modifier 62 to Get your Game Plan in place for both Codes and Documentation

When two surgeons work together to perform one procedure, each physician’s individual documentation requirements can get jumbled up.  Make sure your physician isn’t passing the documentation buck and that he or she knows to follow these four tips when you submit claims with modifier 62.

Tip 1: Each physician should identify the other as a co-surgeon. Also make sure that the other physician is billing with modifier 62. A lot of confusion can arise when physicians from different practices are reporting the same procedure.

You may find yourself in a situation where one physician may report the other physician’s work as that of an assistant surgeon, in which case the claims would not correspond. This means a denial will hit your desk. One surgeon cannot simply indicate the other as the co-surgeon. Both physicians must submit claims for the same procedure, both with modifier 62. To accomplish this all you only need to call with a simple courtesy to the other physician’s billing or coding department.

Tip 2: Each physician should document her own operative notes. When surgeons are acting as “co-surgeons,” it is implied that they are each performing a distinct part of the procedure, which means they can’t “share” the same documentation. Each physician should provide a note detailing what portion of the procedure he or she performed, how much work was involved, and how long the procedure took. Including a brief explanation of the need for co-surgeons will help to avoid denials and reimbursement delays.

Tip 3: Each physician must link the same diagnosis code to the common procedure code. Though this requirement may seem obvious, if two physicians serve as co-surgeons to perform one procedure, the diagnosis code(s) they link to the CPT® code should be the same.  Before submitting a claim with modifier 62, someone…

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64704 Denials? 5 ways to Fix Your Neuroplasty Claims

If you’re just plodding though nerve surgery claims, you could be stepping over a great deal of well-earned reimbursement.  Coding and billing peripheral nerve surgeries for conditions such as tarsal tunnel and diabetic neuropathy can involve a frazzling number of codes.   Podiatry coders often struggle to navigate the various coding guidelines that payers use for these procedures.  Use these five tips to maximize payment for your podiatrist’s hard work on nerve surgeries:

Tip 1: Check CCI edits and your local Medicare guidelines

If you’re billing codes that the Correct Coding Initiative bundles together — and your documentation and diagnosis codes can’t justify breaking the bundle — you’re not going to see one extra cent for that bundled procedure code.

Example: A California Medicare patient injures his foot when he falls off a ladder and requires peripheral nerve surgery to correct the damage the injury caused.  The podiatrist performs the following:

28035 — Release, tarsal tunnel (posterior tibial nerve decompression)

64712 — Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve

64704 — Neuroplasty; nerve of hand or foot

+64727 — Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

64708 — Neuroplasty, major peripheral nerve, arm or leg, open; other than specified.

If you report all these codes, you’re bound to get a denial on 64704 — this is one of the codes the Correct Coding Initiative (CCI) bundles into 28035.  Unless you can justify billing 64704 separately (and if that’s the case, append modifier 59, Distinct procedural service, to the code), you shouldn’t list it all.

Unbundling is not automatic: Be aware that you can’t automatically override a CCI edit with modifier 59 just because documentation supports a separate site,…

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Follow 4 Simple Tips for Modifier 62 to Get your Game Plan in place for both Codes and Documentation

When two surgeons work together to perform one procedure, each physician’s individual documentation requirements can get jumbled up. Make sure your physician isn’t passing the documentation buck and that he or she knows to follow these four tips when you submit claims with modifier 62.

Tip 1: Each physician should identify the other as a co-surgeon.  Also make sure that the other physician is billing with modifier 62. A lot of confusion can arise when physicians from different practices are reporting the same procedure.

You may find yourself in a situation where one physician may report the other physician’s work as that of an assistant surgeon, in which case the claims would not correspond. This means a denial will hit your desk. One surgeon cannot simply indicate the other as the co-surgeon.  Both physicians must submit claims for the same procedure, both with modifier 62. To accomplish this all you only need to call with a simple courtesy to the other physician’s billing or coding department.

Tip 2: Each physician should document her own operative notes. When surgeons are acting as “co-surgeons,” it is implied that they are each performing a distinct part of the procedure, which means they can’t “share” the same documentation. Each physician should provide a note detailing what portion of the procedure he or she performed, how much work was involved, and how long the procedure took. Including a brief explanation of the need for co-surgeons will help to avoid denials and reimbursement delays.

Tip 3: Each physician must link the same diagnosis code to the common procedure code. Though this requirement may seem obvious, if two physicians serve as co-surgeons to perform one procedure, the diagnosis code(s) they link to the CPT® code should be the same.  Before submitting a claim with modifier 62, someone…

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4 Amazing Ways to Code for ‘Get Acquainted’ Visits

Do you ever meet with parents before their baby is even born?  In these cases, you might be hesitant to charge for the visits because the patient isn’t present yet—but can you collect anything for the physician’s time?  Check out the following 4 options, along with our expert advice before billing to insurance.

1. Consider an Office Visit

Some practices think of meet-and-greets, in which they tell the parents about the way they run their practice, more as an office visit, such as 99201.  However, this would need to be billed based on time to the mother’s insurance company and would likely be questioned by the insurance company.  For practices that do charge for these services, there’s a diagnosis code you can use: V65.11. ICD-9 guidelines allow you to list the code as a first or additional diagnosis.

2. Ensure You Meet Criteria Before Using 99401-99404

As an alternative to use a problem-oriented office visit code, the American Academy of Pediatrics (AAP) suggests the pediatrician may deem an appropriate counseling or risk factor reduction code.  You may report these codes for prenatal counseling “if a family comes to the pediatrician/neonatologist either self-referred or sent by another provider to discuss a risk-reduction intervention (i.e., seeking advice to avoid a future problem or complication),” according to the AAP’s Coding for Pediatrics 2009.

You would report the service under the mother’s insurance, according to the AAP. Make sure you don’t use 99401-99404 if the mother or her fetus has any existing symptoms, an identified problem, or a specific illness.  As per CPT®’s Counseling Risk Factor Reduction and Behavior Change Intervention guidelines, “these codes are used to report services for the purpose of promoting health and preventing illness or injury.”

Codes 99401-99404 aren’t necessarily shoo-ins for typical meet and greets.  The AAP gives…

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3 FAQs Banish Your Coding Frustrations on Vaginal Cuff Repair

Find out what colporrhaphy code you’ll use for an injury repair.

If you’re stuck trying to figure out what code to use for a vaginal cuff repair, you should ask yourself one main question: Why did the ob-gyn need to perform the repair?  The answer is the best way to decide what code (and possibly modifiers) to choose.  Follow these three expert steps, and you’ll find the solution to one of the most frequently asked questions in an ob-gyn office: “Which CPT® code should I use for repair of vaginal cuff?”

Q1: How Do I Decide What Repair Code to Use?

The first thing you should do when the ob-gyn performs a vaginal cuff repair is examine the operative report to determine why the patient required the repair, says Cindy Foley, Billing Manager for three separate gynecology practices in Syracuse, N.Y.

Q2: If Repair Dealt With Loose Sutures, What Should I Do?

You read your op notes and discovered the vaginal cuff repair dealt with loose sutures.  Suppose the patient, who underwent a total abdominal hysterectomy (58150, Total abdominal hysterectomy corpus and cervix], with or without removal of tube[s],with or  without removal of ovary[s]), needs to return to the operating room for a vaginal cuff repair because the original sutures became loose and a simple re-closure is documented.  In this case, you should report 58999 (Unlisted procedure, female genital system [nonobstetrical]). You would also need to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did, says Melanie Witt, RN, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.

Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note. For example, you might consider comparing the work to 12020 (Treatment of superficial wound dehiscence; simple closure), which…

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