Does One-Hour E/M Warrant Add-on Prolonged Service Code?

Question: Our physician provided a one hour E/M service, most of which was spent on counseling, so we reported 99215 and one unit of +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient c...

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Surgical Coding: Follow Hernia Bundling Rules

Did you factor in a foreign body removal code?

Question: During an open hernia repair for a reducible umbilical hernia, the surgeon finds a sizeable gallstone embedded in the omentum extending into the preperitoneal fat. The surgeon excises the...

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Separate Sleep Study Coding from Your H&P Coding

Don’t separately report a cursory H&P from the sleep code.

Question: If a nurse practitioner (NP) performed an H&P (history and physical exam) or a subsequent visit with a patient prior to a sleep study, can you bill the H&P...

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Coding Keloid Scar Removal

Watch out: Avoid this unlisted code. Question: Is removal of a keloid scar considered an unlisted procedure? What is the right code? Answer: Use 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions) with diagnosis 701.4 (Keloid scar). 17110 and 7111 [...] Related articles:

  1. Check Destruction Method Before Assuming 17110You could gain $30 if a shave is also performed....
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How Do I Code an Epidural Blood Patch on Same Day as L&D

Don’t forget to double-check these 2 things to find the correct code. Question: How do I code an epidural blood patch procedure on the same day as labor and delivery? Should I include a modifier? Answer: Administering a blood patch on the same day as labor and delivery is unusual because most physicians try to manage spinal [...] Related articles:

  1. 64450 or 64421: Which Code to Tap for TAP Block?Question: What exactly is a “tap block,” and what code...
  2. How Do I Code Blood Draw Plus E/M?Question: An established type II diabetic patient comes in for...
  3. Will S Code Pay Off for Cord Blood Collection?Question: My ob-gyn did cord blood collection. I have these...

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ED Coding Question: Observation or Other E/M Code?

Question: A 42-year-old patient reports to the ED early on Tuesday morning for evaluation of uncontrollable shaking in her extremities and severe pain in her neck. The EP admits the patient to observation at 7 a.m. and orders blood tests and a CT scan — however, the shaking continues to worsen. The EP consults with a [...] Related articles:

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  2. 5 Steps Ensure Correct Observation Care Coding To prevent ED denials, code service only when doc...
  3. Observation Coding Do’s and Don’ts What’s the POS for an ED hallway? Answers to...

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Is 30901 Your Nosebleed Code? Not So Fast?

Hint: Look for these keywords in the note to select the correct nosebleed code. Question: The internist stops a patient’s nosebleed. Is this always a procedure? Answer: No, if a patient reports with a nosebleed and the physician stops the bleeding with basic methods, you’ll typically opt for the appropriate-level E/M code. E/M methods: Code minimal attempts at [...] Related articles:

  1. Can You Code ‘Buddy Taping’ Separately? Question: An established patient complains of pain in her...
  2. Should You Code Presenting Symptoms Along With Dx? Question: An established patient complains of trouble breathing and...
  3. How Do I Code Blood Draw Plus E/M?Question: An established type II diabetic patient comes in for...

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How Do You Code Sigmoidoscopy with Anoscopy, Biopsy?

Question: Notes indicate that the gastroenterologist performs a rigid sigmoidoscopy; during the encounter, he also performs an anoscopy without anesthesia and three biopsies of the mucous membrane. How should I report this episode? Can I report the exam separately with 46600? Answer: You can report a single code for these three services. On the claim, report 45305 (Proctosigmodoscopy, rigid; with biopsy, single or [...] Related articles:

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