Don't have a TCI SuperCoder account yet? Become a Member >>

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
MIPS:
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
Bundling:
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
Endoscopy:
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