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General Surgery Coding Alert

Perfect Your ICD-10 Claims With These 3 Tips
Hint: Don’t rely on GEMs. Maybe you’re still struggling with your transiti... Read more
Medicare Physician Fee Schedule:
Get These Updates to Global Surgical Package and Incident-To Billing
Fees and compliance issues lead surgeons’ concerns. First, the good news —... Read more
HIPAA Compliance:
Get Ahead of Notification Curve for PHI Breach
  Avoid stiff penalties that could hurt your practice. With fines ranging from ... Read more
Reader Question:
Fulfill Critical Care Criteria to Use Codes
Question:One of the surgeons in our practice thinks that when he rounds on a patient in ... Read more
Reader Question:
Pinpoint POS Codes with This Quick Guide
Question: I have heard that MACs are paying close attention to our place of service... Read more
Reader Question:
Select Modifier for Incomplete ERCP
Question: During an ERCP procedure, the surgeon made numerous failed attempts with ... Read more
You Be the Coder:
Earn $139 With Accurate Lesion Measure
Question: One of our surgeons reports malignant lesion excision by stating the dime... Read more
CPT® 2016:
Rev Up Your General Surgery Coding for Next Year
Anticipate changes for cholangiography and billiary drainage. Ignorance isn’t bl... Read more
Clip and Save:
CPT® 2016 Surgery Code Overview
Keep this chart for reference in the New Year. We’ve gathered the new, revised, ... Read more
Understand Grace Period
Check out these resources, too. You’re using ICD-10, and you’re not too su... Read more
CPT® 2016:
Get Ready for 2 New Prolonged Services Codes
And make sure to update 2 more. General surgeons may not be the best about keeping on ... Read more
Reader Question:
Let Tumor Type Lead Code Choice
Question: We had a case involving a melanoma re-excision of 11 cm by 3.3 cm (excise... Read more
Reader Question:
Seek Margin Documentation for Lumpectomy
Question: Our surgeon excised breast tissue in a procedure he described as a &ldquo... Read more
Reader Question:
Don't Forget Angioplasty Guidance
Question: What is the correct way to code one angioplasty in the femoral artery and... Read more
You Be the Coder:
Beware Medical Records Rules
Question: We discharged a patient due to non-payment, and one week later a new surg... Read more
CPT® 2016:
Meet Proposed Changes for Larynx Codes and More
Look to vascular codes, too. The final touches on CPT® 2016 are underway, and we h... Read more
Update Laryngeal Cancer Coding This Fall
Change ‘other’ to ‘overlapping. Not much changes but the code number... Read more
Grasp 'Incident-to' Opportunity for NPP Pay
No dice for new patient or plan. If you have non-physician practitioners (NPPs) workin... Read more
Physician Fee Schedule:
Get to Know Proposed 'Incident-to' Changes
Just one physician will do. You just honed your “incident-to” coding skill... Read more
Reader Question:
Use 'G' Code for Medicare Closure
Question: We have one surgeon who likes to use tissue adhesive instead of placing a... Read more
Reader Question:
Distinguish Chronic, Acute in Medical Record
Question: Does ICD-9 have a default way to code acute versus chronic if the medical... Read more
Reader Question:
Outline Consultation Requirements
Question: Other physicians often ask surgeons in our practice for a consultation on... Read more
Reader Question:
Use "Other" ICD-10 Codes With Caution
Question: If I find that a common ICD-9 code that I use doesn’t have a direct... Read more
You Be the Coder:
Detail Maloney Bougie Dilator
Question: Our surgeon performed an esophagoscopy on a Medicare patient before the i... Read more
EVAT Case Study:
Missed Method and Site Could Cost Your Surgeon $600+
Coding by access site is key. If your general surgeon performs vascular procedures, s... Read more
Location, Complications Expand Varicose Vein Options
Tell your surgeons to give more specific documentation. When you report lower-extre... Read more
ICD-10 Update:
You Might Avoid Claims Denials in the Implementation Year
Get to the right code family. You won’t be able to keep using ICD-9 beginning Oc... Read more
Focus on Diagnosis:
4 Tips Highlight ICD-10 Changes
Welcome combination codes and seventh digits. By now you should be familiar with basic... Read more
Reader Questions:
Deal with New Medicare 'Opt Out' Process
Question: Our surgery practice has chosen to opt out of Medicare. I heard that ther... Read more
Reader Questions:
Look for 'Separate Procedure' Bundles
Question: We have an op note that states that the surgeon injected air into the per... Read more
Reader Questions:
Express Halted Surgical Procedure Using Modifier 53
Question: Our surgeon prepped and positioned a patient for repair of a recurrent in... Read more
Reader Questions:
Account for Enterolysis Work
Question: The surgical note states that during a laparoscopic procedure, the surgeo... Read more
Reader Questions:
Compare Complex and Intermediate Closure
Question: Please help me code this note: Treated 10 cm linear laceration of right... Read more
You Be the Coder:
Don't Miss Combination Code
Question: The op note indicates that during a flexible sigmoidoscopy procedure, the... Read more
Lower GI:
Generate Clean EUS Claims With This Advice
Don’t miss parallel FNA codes. When your general surgeon performs an endoscopic ... Read more
Diverticulitis Diagnosis:
Add Perforation and Abscess Details for ICD-10
Prepare your surgeons to add op-note detail. Whether the patient’s colon diverti... Read more
Diagnosis Coding:
Focus Your ICD-9 to ICD-10 Transition With 3 Tips
Prime your general surgeons for reporting laterality and other detail. Whether you&rsq... Read more
ICD-10 Readiness:
Conquer These Steps to Smooth Your ICD-10 Transition
Your work doesn’t end on Oct. 1. Now that you have a grasp of what to expect as ... Read more
Reader Questions:
Focus Cyst Coding with These Tips
Question: What is the correct diagnosis code for a sebaceous cyst of the hip/pelvic... Read more
Reader Questions:
Learn 4 x 4 E/M Trick
Question: What is the “4 x 4 rule” as it pertains to E/M coding? Wash... Read more
You Be the Coder:
Don't Miss Separate Angioplasty Opportunity
Question: What is the best way to report an angioplasty and vacuum thrombectomy of ... Read more
Tonsils and Adenoids:
Avoid Bundling Pitfalls for Clean Tonsillectomy Claims
Take this modifier 50 tip to the bank. When billing tonsillectomy and/or adenoidectomy... Read more
1 Code for Malignant Tonsil? - Not Any More
Don’t forget additional code. You’ve had it pretty easy up until now &mdas... Read more
Quality Reporting:
Ignore PQRS at Your Peril - Penalties Await
Get ready for VBPM, too.  If you haven’t sorted through the quality-measure... Read more
See Which Quality Measures Apply
Check CMS’s complete list for your practice. Depending on the type of procedures... Read more
Reader questions:
Capture Separate E/M in Post-Op Period
Question: Our surgeon performed a rubber band ligation to treat hemorrhoids. Three ... Read more
Reader questions:
Do This to Secure Bluetooth Devices
Question: Our surgeons use smart phones and tablets with Bluetooth capability, and ... Read more
Reader questions:
Look for Separate Scope Services
Question: Our physician recently performed a colonoscopy with polypectomy and also ... Read more
You Be the Coder:
Exploit 'Initial Vessel' Opportunity
Question:How should I report the following procedures, which are from an antegrade appro... Read more
Vascular Surgery:
Perfect Your IVC Filter Coding With These 3 Steps
Capture steps for insertion, repositioning, and removal. When your general surgeon man... Read more
453.5 Crosswalks to Multiple Specific Vein Codes
Get more info to accurately report chronic DVT cases. Just one ICD-9 code tells the... Read more
Medicare Pay:
Usher Out SGR Formula - For Good
Expect new quality pay plan(s). You won’t ever have to cross your fingers again ... Read more
Modifier Update:
CMS Speaks: X{EPSU} Offers 'No Benefit' For Now
You may keep using 59 until further notice.  Many surgery practices have been get... Read more
Reader Questions:
Distinguish Facility vs. Non-Facility Fees
Question: Can you please explain whether we should use the facility global fee or t... Read more
Reader Questions:
Check Stent Procedure Documentation
Question: How should I code the following open surgical case: The surgeon isolated ... Read more
Reader Questions:
Roundup Multiple Codes for Anal Botox
Question: Our surgeon performed Botox injections to treat anal fissures. How should... Read more
You Be the Coder:
Watch for Adjacent Tissue Transfer Included Services
Question: If the surgeon excises a 2 x 4 cm carcinoma of the face, and closes the e... Read more
CPT® 2015:
Capture Cannula Services for ECMO Patients
Your surgeon may be part of the life support team. If you thought you could ignore CPT... Read more
Expand Options for Newborn Respiratory Distress Syndrome
Fourth digit adds detail. No matter the details, you have just one code to describe... Read more
No Joke: Deal With April 1 Pay Cut
Hope for Senate action after recess. The Senate wasn’t fooling when it went on b... Read more
Face 5 Trends That Could Impact Your Compliance in 2015
Watch out for state-law violations.  Maybe you know that your general surgery pra... Read more
Reader Questions:
Limit Unlisted Code for Colonoscopy Through Stoma
Question: Our surgeon performed a colonoscopy through a stoma for a patient with a histo... Read more
Reader Questions:
Let Lap Band Component Lead Code Choice
Question: We have a surgical report that describes a laparoscopic procedure in whic... Read more
Reader Questions:
Note Vein and Laterality for DVT Treatment
Question: What documentation should our vascular surgeons provide for DVT diagnosis... Read more
You Be the Coder:
Beware Bundled EGD Services
Question: If the surgeon performs an EGD with biopsy, and documents control of blee... Read more
CPT® 2015:
Capture the Pay You Deserve With This Roadmap for Lower GI Procedures
New definitions lead the way. If you’ve ever gotten confused about which type of... Read more
Add Complications to Crohn's Codes
Crosswalk expands with 6th digit. Just like ICD-9, you’ll find four codes for re... Read more
Simple or Intermediate: Focus Laceration Coding With 4 Tips
Extensive debridement can change everything. You may think that coding for simple or i... Read more
ICD-10 Prep:
Get Ready With These Testing Opportunities
Await July application deadline. Maybe you’re sure your general surgery practice... Read more
Reader Question:
Distinguish Excision, Destruction Procedures
Question: When I have a surgical report for removal of in situ basal cell carcinoma... Read more
Reader Question:
See How Single Mesh Impacts Code Choice
Question: The surgeon performed a laparoscopic inguinal hernia repair on the right ... Read more
Reader Question:
Don't Fear ICD-10 Transition
Question: I’ve been told that ICD-10 will be nearly impossible to use because... Read more
Reader Question:
Ensure Encryption to Avoid HIPAA Breach
Question: If our general surgery practice uses unencrypted email to send a report w... Read more
You Be the Coder:
Narrow Hernia Coding With Documented Details
Question: The surgical report documents laparoscopic repair of a reducible trocar-s... Read more
Medicare Physician Fee Schedule:
Watch for Possible April Pay Cut
But an act of Congress can save the day. So far this year, you should be experiencing ... Read more
CPT® 2015:
Digest Massive Endoscopy Coding Update
Greet new families for stomal procedures. If you remember all the changes to the esoph... Read more
Add Perforation and More to Your Diverticulosis Choices
Don’t forget bleeding indication. If your surgeon performed procedures today tha... Read more
Practice Management:
Use These OIG Tips to Solidify Your 2015 Compliance Plan
Follow 7 tips to meet ACA requirements. You should start the New Year right by pledgin... Read more
Reader Question:
Meet Criteria to Bill Consultation
Question: A new patient came to see a surgeon in our practice to discuss whether she ... Read more
Reader Question:
Beware IRC Global Period
Question: Our surgeon saw a patient in the office, and advised a subsequent visit t... Read more
Reader Question:
Distinguish Simple, Intermediate, Complex Closure
Question: The surgeon repaired an 8.3 cm gash on a patient’s chest. The wound... Read more
You Be the Coder:
Consider Source, Location for Removal Code Selection
Question: A patient with a prior gallstone surgery presents with a painful, fibrous... Read more
CPT® 2015:
Squash 'Abridged Colonoscopy' Coding Debate
New ‘decision tree’ defines choices. General surgery coders have long deba... Read more
Physician Fee Schedule:
Greet 10 'G' Codes for Lower GI Procedures
Accommodate double standards based on payer. Maybe you’re thrilled that CPT®... Read more
Locate Hyperplastic Polyps for ICD-10
211.3 crosswalks to more specific codes. Because they’re non-neoplastic, you&rsq... Read more
Correctly Choose Modifier 52 or 53 -- Every Time
Unscramble ‘reduced’ and ‘discontinued’ procedures. When your ... Read more
Reader Question:
Expect Record Review to Be Part of Office Visit
Question: A patient had 10 years of medical records sent to our physician for revie... Read more
Reader Question:
Unravel Subsequent vs. Initial for Hospital E/M
Question: On a recent claim, I used a CPT® code for subsequent hospital care to... Read more
Reader Question:
Bleeding Drives Gastric Varices Code Choice
Question: How should I report a surgeon’s treatment of gastric or esophageal ... Read more
Reader Question:
Expand Keratoderma Choices in ICD-10
Question: Our surgeon excised a skin lesion which the pathology report diagnosed as... Read more
You Be the Coder:
Bundle Same Vascular Family and Approach
Question: Can I bill 36215 and 36216 together for a first and second order thoracic... Read more
CPT® 2015:
37218 Adds Carotid Stent Coding Option
Bundle angioplasty and more to match code revisions. Both opportunities and restrictio... Read more
I65.2 Expands Carotid Artery Stenosis Options With 'Right' and 'Left'
Drop 433.10 beginning Oct. 1. Carotid artery stenosis might be a common reason your ge... Read more
CCI Impact:
Check Your Modifier 59 Use in 2015
Get ready for 4 new X{EPSU} choices. You probably rely on modifier 59 (Distinct proced... Read more
Medicare Errors:
Let CERT Findings Focus E/M Claims
Avoid key documentation mistakes that cost you pay. Imagine if you lost 10 percent of... Read more
Reader Question:
Clarify Teaching Physician Claims
Question: Our surgeon sometimes has a resident assist in surgery at a teaching hospital.... Read more
Reader Question:
Document Donor Site to Code Advancement Flaps
Question: Our surgeon closed a deep abdominal wall defect that was approximately 440 sq.... Read more
Reader Question:
Add to Your ICD-10 Know-How
Question: I’ve heard that ICD-10 doesn’t have an equivalent to V codes and E... Read more
You Be the Coder:
See How Physicians Can Discuss PHI
Question: Our general surgeon wants to talk to another physician about a patient’s... Read more