Tag Archives | Cpt Coding

How to Code for ‘Problem’ Discovered During Preventive Medicine Visit

The Current Procedural Terminology (CPT) manual offers guidelines on how to code for a “problem” that is addressed during a preventive medicine service. The guidelines cover “insignificant or trivial” problems as well as those that are “significant.” “An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and […]

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Move Provider Signature To The Top Of Your Documentation

Checklist Extra: The physician’s credentials have a role to play, too.

Your CPT® coding may be spick and span, but if you fail to fulfill your physician signature requirements, your claims could end up in hot waters because not following these rules can trigger audits and other compliance headaches. Getting your provider to sign your patient’s charts is a basic documentation prerequisite that calls for your relentless compliance.

Basic: The treating physician’s signature serves as a legible identifier for the provided/ordered services. Payers require that the signature must be present in the documentation that comes with your claim.

Check out the following Q&A and find out why stamped signatures just won’t do you any good.

Get to the Bottom line Of Handwritten vs. Electronic Signatures

Question 1: Some of our physicians use handwritten signatures on their charts and others prefer electronic signatures. Is either kind acceptable?

Answer 1: According to CMS,, “Medicare requires a legible identifier for services provided/ordered.” That “identifier” — or signature — can be electronic or handwritten, as long as the provider meets certain criteria. Legible first and last names, a legible first initial with last name, or even an illegible signature over a printed or typed name are acceptable. You’re also covered if the provider’s signature is illegible but is on a page with other information identifying the signer such as a typed name.

“Also be sure to include the provider’s credentials,” says Cindy Hinton, CPC, CCP, CHCC, founder of Advanced Coding Solutions in Franklin, Tenn. “The credentials themselves can be with the signature or they can be identified elsewhere on the note.”

Example: Pre-printed forms might include the physician’s name and credentials at the top, side, or…

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CPT 2011: Pay Attention To These New Joint Injection Guidelines

Remember to check for updated or revised guidelines when preparing to use your new code books for 2011, not just code descriptors. CPT 2011 includes new details for coding some common injection procedures, as pointed out at the AMA’s CPT and RBRVS 2011 Annual Symposium in Chicago. Read on for a few pointers to help stay on the right track.

The introduction of new codes for paravertebral facet joint injections in 2010 (64490-64495) meant changes to how you reported related codes. During the CPT and RBRVS Symposium, Douglas G. Merrill, MD, MBA, of the American Society of Anesthesiologists, pointed out two revised guidelines dealing with paravertebral facet (spinal) joint procedures.

Instructions in CPT 2010 directed you to report 64999 (Unlisted procedure, nervous system) if the provider used ultrasound guidance during paravertebral facet joint injections. The AMA released a correction later in 2010, and the CPT 2011 clarifies the situation. If your provider used ultrasound guidance when administering paravertebral facet joint injections, report the appropriate code(s) from 0213T-0218T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance …).

T12-L1 change: CPT 2010 guidelines mandated that you report 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [for nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) for an injection to the T12-L1 joint, or nerves innervating that joint. New 2011 guidelines direct you to submit 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [for nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single) instead.

In addition, the 2011 guidelines direct providers to report paravertebral facet joint injections performed without image guidance with the appropriate trigger point injection code. Submit either 20552 or 20553 (Injection[s]; single or multiple trigger

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Ace CPT and ICD-9 Coding for Intra-Arterial Cases

Whether liver neoplasm is primary or secondary will change your coding.

Good news: You can apply many of the same rules you already know for intravenous chemotherapy coding to intra-arterial coding, too. So take your chemo coding expertise to the next level by adding intra-arterial skills to your arsenal.

Start here: For intra-arterial (IA) chemotherapy, you should choose from the following codes, says Gwen Davis, CPC, associate with Washington-based Derry, Nolan, and Associates.

  • 96420 — Chemotherapy administration, intra-arterial; push technique
  • 96422 — … infusion technique, up to 1 hour
  • +96423 — … infusion technique, each additional hour, (List separately

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Ensure Multi-Vaccine Payment With This Coding Advice

You may need to append modifier 25, depending on payer policies.

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we

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Radiology Coding Challenge: Why is Medicare Denying a 38792, 78195 Claim

Tip: Discover true meaning of 38792 note
Question: The physician performed a sentinel node injection with lymphoscintigraphy. A note with 38792 states to report 78195 for imaging. So why did Medicare deny a claim that included both codes?
Answer: You should report 78195 (Lymphatic and lymph nodes imaging) for this service and leave 38792 (Injection procedure; for […]

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CMS Will Offer New Modifier to Denote Admitting Physician on Claims

Pop the champagne cork & get ready for brand new inpatient coding rules.
With the changes to consult coding in 2010, it will be more important than ever to report hospital visits properly.
In the past, only the admitting physician reported initial hospital care codes (99221- 99223), and specialists who saw the patient separately often billed inpatient […]

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