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General Surgery Coding Alert

Case Study:
Skip 38531 for Laparoscopic Lymph Node with Hernia Repair
Focus on rules for ‘unlisted' procedures. Take a peek at the following case to garner t... Read more
Modifier Mastery:
Chart These Surgical Examples for Modifier 58 Victory
Pre-planning exemplifies staged procedures. You might lose the procedure pay you deserve ... Read more
Life Support:
4 Tips Create Clean ECMO Claims
Master cannula placement codes and more. If you have surgeons who are sometimes part of a... Read more
You Be the Coder:
Distinguish 3 Anal Fistula Codes
Question: The op report describes the surgeon identifying an internal anal fistula op... Read more
Reader Question:
Improve Your E/M Time Coding Accuracy
Question: I'm confused about coding E/M services by time. Do we have to document the ... Read more
Reader Question:
Include India Ink in Surgery
Question: During a colonoscopy, the surgeon used a snare to remove two polyps from differe... Read more
Reader Question:
Master Modifier 25 Tips
Question: Our surgeon saw an established patient in the office to examine a third-deg... Read more
Needle Procedures:
Confusing FNA and PNB Could Cost You
Look for three distinguishing features in the op report. If you've ever looked at an op r... Read more
E/M Coding:
Make Sure Time is on Your Side for Encounter Upgrade
‘Counseling exception' is key. When your surgeon spends time counseling a patient and c... Read more
2 Keys Unlock Audit Preparedness
Secure data for six years. Participating in the Merit-Based Incentive Payment System (... Read more
You Be the Coder:
Focus Undescended Testes Case
Question: Our surgeon treated an 11-month-old with bilateral undescended testes. The op re... Read more
Reader Question:
See What Dialysis Circuit Includes
Question: Please help me understand how to code the following case: Using fluoroscopic gui... Read more
Reader Question:
Report Relevant Post-Surgical ICD-10 Codes
Question: Following a Whipple procedure involving a total pancre­atectomy that our surgeo... Read more
Reader Question:
Beware HIPAA Compliance Claims
Question: Our office purchased encryption software that claims to be “100-percent HIPAA ... Read more
Lymph Node Biopsy:
3 Expert Tips Distill Perfect 38531 Use
Don't miss bilateral pay. You've long had specific codes for open lymph node biopsies fro... Read more
Don’t Miss ‘Extensive’ Adhesiolysis Opportunity
Make modifier 22 your friend. What can you do when your surgeon documents an abdominal or... Read more
Separate E/M:
Master Modifier 25 Essentials for Better Pay
Don't conflate modifiers 57 and 25. Finding both an E/M service and a surgical procedure ... Read more
You Be the Coder:
Remember Multiple-Endoscopy Rule
Question: An endoscopic PEG tube placement procedure required some extra work, and I'm won... Read more
Reader Question:
Hospital Admission Leads Consult Code Choice
Question: Our surgeon saw a non-Medicare patient in the office for a consultation, and the... Read more
Reader Question:
Identify Site For Line Procedure Coding
Question: I have an op report that documents a central line, arterial line, and a Swan-Gan... Read more
Pancreas Surgery:
4 Steps Focus Whipple Code Selection
Identify approach, excisions, and resections. Surgical treatment for pancreatic cancer mi... Read more
ICD-10 Essentials:
Heed Excludes1 Notes For Clean Claims
Turn to the latest Coding Clinic for clarification. Maybe you groan when you turn to an I... Read more
OIG Report:
Make Sure You’re Ready for CMS’s Audit Spotlight
Code utilization could be a problem. With a recent focus on CMS's audit-recovery success,... Read more
You Be the Coder:
Find Lipoma Depth for Code Selection
Question: The op note states that the surgeon removed a “5 x 5.5 cm mobile lipoma” fro... Read more
Reader Question:
Limit +49568 to Specific Hernia Cases
Question: Can we separately bill mesh placement using code +49568 for hernia repairs? Ind... Read more
Reader Question:
Think ‘A’ for ‘Active’ Encounter
Question: Our surgeon removed sutures from a patient new to our practice who had a right-t... Read more
Reader Question:
Get Your CMS Info in Podcast Form
Question: I heard CMS now has a podcast to update policy information. Is that true, and if... Read more
Reader Question:
Focus ICD-10 For Bladder Cancer Dx
Question: Our surgeon took a bladder biopsy using a cystoscope and in the op report, descr... Read more
Rouse Your Procedure and Dx Skills for This GI Case
Biopsy changes everything. When your surgeon performs multiple endoscopies on the same da... Read more
CPT® 2019:
Grapple With New Technology Options for E/M Services
Check perspective for 99451, 99452. Whether an E/M service involves internet, telephone, ... Read more
Modifier Focus:
Avoid 59 Fatigue With 3 Tips
Brush up on CMS guidance. Before you use modifier 59 (Distinct procedural service) again,... Read more
You Be the Coder:
See How G0513 Can Add Up for Colonoscopy
Question: Can we use the prolonged service codes G0513 and G0514 for screening colonoscopi... Read more
Reader Question:
Know Your Nose and Throat Anatomy
Question: The op note documents that the surgeon inserted a scope through the nose to exam... Read more
Reader Question:
Don’t Miss Physician CCM Code
Question: Is there a way to report chronic care management when the physician provides the... Read more
Reader Question:
Check Out ABN Modifier Choices
Question: We have an ABN notice for a patient's low-risk screening colonoscopy becaus... Read more
CCI Edits:
Navigate Surgery Bundles That Could Compromise Your Pay
Modifier indicator is key. Like most first-quarter Correct Coding Initiative (CCI) update... Read more
ICD-10 Changes:
Master Guidelines for Infection, Sepsis
Neglect sequencing rules at your peril. Each year, we rush to learn “new codes, new cod... Read more
HIPAA Compliance:
Protect Patients With New HHS Cybersecurity Guidance
Learn best practices for your needs. Along with electronic health records (EHR) and other... Read more
Reader Question:
Spotlight CF: 1 Factor for Medicare Fees
Question:  What is the “conversion factor,” and how does it impact Medicare payme... Read more
Reader Question:
Look for Separate Appendectomy
Question: While performing an open gallbladder removal, the surgeon noted localized perito... Read more
Reader Question:
Prepare for LCD Changes
Question: I heard that Medicare is changing LCDs to eliminate ICD-10 codes. Does that... Read more
You Be the Coder:
Axillary Lymphadenectomy is Total
Question: The listed procedure on the op note is “partial mastectomy,” but the su... Read more
Case Study:
Don’t Miss Hernia Pay With This Colon Resection Case
Learn rules for separate services. When your surgeon identifies and repairs a hernia in t... Read more
2019 Medicare Pay:
Grasp MPFS Final Rule Impact for Your General Surgery Practice
Don't miss telehealth expansion. With payment and policy changes that could impact your g... Read more
2019 Final Rule:
MPFS Staggers Rollout of E/M Overhaul
Look for documentation relief this year. CMS' 2019 Medicare Physician Fee Schedule (MPFS)... Read more
Reader Question:
Attend to Medicare Copays and Deductibles
Question: Must we always collect Medicare patient copays and deductibles, and how do I kno... Read more
Reader Question:
Toenail Matrix Drives Code Choice
Question: A patient presented with a big toenail that was torn almost completely away from... Read more
Reader Question:
Note Details Guide Hemorrhoidectomy Coding
Question: Our surgeon excised a second-degree internal hemorrhoid group due to uncontrolla... Read more
Reader Question:
Distinguish Additional Lesion Excision Method
Question: The surgeon performed a skin wedge biopsy followed by a punch biopsy for a separ... Read more
You Be the Coder:
Use Just One Polyp Code
Question: Please help me code this op note: Surgeon resected and retrieved an 8 mm polyp i... Read more
CPT® 2019:
Master Integumentary Biopsy Code Overhaul With 4 Tips
Technique documentation leads code choice. Almost nothing is left of the skin-biopsy sect... Read more
Assistant Surgeon:
Sort Out 3 Modifier Choices for Clean 'Assistant' Claims
Count on ‘80' as your work horse. However, complicated an op report might seem when you... Read more
Practice Management:
Duck Signature-Error Denials With These Steps
Don't lose pay over this easy compliance fix. Even a coder who's mastered CPT® and ICD-1... Read more
Reader Question:
Get Detailed for Intestinal Obstruction Dx
Question: I'm used to certain basic diagnoses that we face all the time, like intestinal o... Read more
Reader Question:
Don't Bundle E/M and X-ray
Question: An established patient reports to the surgeon reporting pain on her right side c... Read more
You Be the Coder:
Distinguish 36821 from 36825
Question: Surgeons in our practice sometimes create vascular access by arteriovenous fistu... Read more