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General Surgery Coding Alert

CPT® Update:
Use 43284-43285 for Esophageal Sphincter Augmentation Device
Look for deleted ‘emerging technology’ codes. If your surgeon performs a ... Read more
CPT® 2017:
Angioplasty Update Means Out With the Old, In With the New
Don’t distinguish new codes by open or percutaneous. You need to relearn how to ... Read more
E/M Briefing:
Tighten Encounter Documentation to Ethically Maximize Pay
Audit-protect your claims. If you or your surgeons get lazy and always report the sam... Read more
Reader Question:
Beware Modifier 'Solutions'
Question: When we see a claims denial in our practice, some of our staff is quick t... Read more
Reader Question:
Bundle RS&I With UFE
Question: Our surgeon performed a diagnostic CT angiography with contrast for a pat... Read more
Reader Question:
Don't Let PICC Line Removal Fool You
Question: When our surgeon replaces a PICC line, we report 36584, but I don’t... Read more
Reader Question:
'Extensive Undermining' Points to Repair Choice
Question: A patient presented with a deep, ragged, debris-filled wound on her abdom... Read more
You Be the Coder:
Capture Distinct FNA Sites
Question: Our surgeon performed an FNA on a palpable 2 cm nodule of the right thyro... Read more
CPT® 2017:
Overhaul Laryngoplasty and Flexible Laryngoscopy Coding
Add lesion ablation and other specific procedure choices. When your surgeon performs a... Read more
ICD-10:
5 Tips Perfect Your Burn Coding
Use ‘X’ placeholder properly. When your surgeon encounters patients for bu... Read more
Compliance:
Your Small Practice Size is No Protection From HIPAA Audit
Keep alert for verification requests. The Office of Civil Rights (OCR) random desk aud... Read more
Reader Question:
78 Modifier Identifies Complication During Global
Question: Our surgeon performed a partial colectomy with anastomosis. Six days late... Read more
Reader Question:
Zero in on Scrotal Hernia Code
Question: The surgeon performs laparoscopic hernia repair for a strangulated left s... Read more
Reader Question:
Report Single AV Shunt
Question: I code for certain dialysis arteriovenous shunt services like angioplasty... Read more
You Be the Coder:
Document EMR Steps
Question: When our surgeon performs an EMR, we find that payment for the claims is ... Read more
CPT® 2017:
Glance Ahead To GI, Vascular, Moderate Sedation Changes and More
Use this overview to see what’s in store for your surgeons’ coding next year... Read more
CCI Edits:
Don't Let Bundling Rules Clog Up Your Vascular Surgery Claims
Know when to override code pairs. If your surgeon performs vascular procedures such as... Read more
Practice Management:
Protect Your Surgical Practice's PHI -- Now More Than Ever
Let recent breach serve as cautionary tale. Did you know that cyberattacks have become... Read more
Reader Question:
What's the Allowable Fee for Medical Records?
Question: The HIPAA Right of Access rules seem to say that we cannot charge more th... Read more
Reader Question:
Choose 'Repair' Level With These Tips
Question: Please look at the following note and suggest the appropriate repair code... Read more
Reader Question:
Separately Bill 2-Stone Removal
Question: Our surgeon removed two stones from the parotid gland. He inserted a sial... Read more
You Be the Coder:
Beware Polypectomy and Ablation Limitations
Question: When the surgeon uses a hot snare to ablate a polyp, then during the same... Read more
Integumentary System:
Master Melanoma Excision Reports With 3 Tips
Watch for separate repair charge. If your general surgeons treat some of the more tha... Read more
Focus Melanoma Diagnosis with Site, Behavior Documentation
Malignant and in situ are different. Most conditions report to a single code family in... Read more
ICD-10-CM Update:
Recognize Abdominal Diagnosis Options Coming Your Way
Don’t miss these new GI tumor codes. As a general surgery coder, you know you ha... Read more
Compliance:
Prepare For Solid Dx Claims As 'Grace Period' Ends
Never miss listing all required digits. If you’ve been relying heavily on CMS&rs... Read more
Reader Question:
Determine 'Clinical Staff' Eligibility for TCM
Question: I work in a general surgery office and have some questions concerning cod... Read more
Reader Question:
Capture EGD Dilation and Biopsy
Question: Our surgeon performed an EGD that required dilation for access. Upon exam... Read more
You Be the Coder:
Clarify 49185 Add-Ons
Question: A patient presented for treatment of a painful Peritoneal Inclusion Cyst ... Read more
Surgical Case:
Focus Codes for Parastomal Hernia 'Sugerbaker' Mesh Repair
Document ‘incarcerated’ for procedure, diagnosis choices. You’ll be... Read more
Procedure Notes:
3 Tips Perfect Your Trach Tube Claims
Watch global days, bundling rules for 31502. If your general surgeon changes a tracheo... Read more
HIPAA Audit:
Maximize Your Plan for Phase 2 Audit Focus
Use protocol tool even if you don’t face audit — this time. Even if your l... Read more
Reader Question:
You Decide -- E/M or I&D?
Question: Our surgeon evaluated a 56-year-old male patient with complaints of pain ... Read more
Reader Question:
Bill For Cyst Contrast Injection
Question: Our surgeon injected contrast into a cyst via a previously-placed cathete... Read more
Reader Question:
Choose 'Benign' for Cherry Hemangioma
Question: I have a surgical report that for excision of a 1.8 cm “cherry hema... Read more
Reader Question:
Focus Laparoscopic Lymph Node Coding and Pay
Question: What is the correct code for a laparoscopic retroperitoneal lymph node di... Read more
You Be the Coder:
Count Stents In Some Circumstances
Question: Treatment for a biliary cancer patient involved placing two separate bile... Read more
CPT® 2016:
3 Steps Direct Biliary Drainage Catheter Coding
Avoid ‘stent’ terminology for emptying bile duct. With five new codes and... Read more
Oral Surgery:
Tongue Site Leads Excision, Diagnosis Code Choices
Closure documentation could earn $162 pay. When your general surgeon performs a tongue... Read more
Place of Service:
Face POS 19 Game-Changer for Outpatient Billing
Distinguish “off-campus” clinics. Since Jan. 1, your practice should have ... Read more
Reader Question:
Modifier 78 Helps Dehiscence Pay
Question: Is repair of wound dehiscence ever payable during the global period? If s... Read more
Reader Question:
Follow Complex Rules for Discontinued Colonoscopy
Question: Our surgeon performed a diagnostic colonoscopy but was unable to get past... Read more
Reader Question:
Don't Forget Sequestration Cuts
Question: Are our surgeons’ Medicare payments still subject to the 2 per... Read more
You Be the Coder:
Scrutinize Primary ICD-10 'Z' Codes
Question: Can we use “Z” codes as a primary diagnosis? For instance, if... Read more
CCI 22.1:
Find Infusions, Tissue Transfer Bundles and More in Latest Update
Know when modifier is an option. When your general surgeon reports multiple CPT® c... Read more
ICD-10:
Get Ready for Dx Updates This October
Cardiovascular system changes and more will impact your practice. After a five-year co... Read more
Medicare:
Pay for 'Quality' Here to Stay
Prepare for MIPS and APMs. Fee for service is on the way out, and the Merit Based Ince... Read more
Reader Question:
Define Angioplasty and/or Atherectomy
Question: Our surgeon performed a “cutting balloon atherectomy.” Servic... Read more
Reader Question:
Recognize Breach Under HIPAA
Question: An employee at our general surgery practice accessed records for which he... Read more
You Be the Coder:
Check Reason for FNA and Biopsy Together
Question: Our surgeon performed a fine needle aspiration of a mediastinal mass. Dur... Read more
CPT® 2016:
Nail Your Percutaneous Biliary Stent Coding With 4 Tips
Code per session, not per stent. In the massive code overhaul of percutaneous biliary ... Read more
ABNs:
Salvage Your Pay for Uncovered Procedures
Signature means you can bill beneficiary. Master the appropriate use of advance benefi... Read more
MPFS Pay:
Blink and Miss Conversion Factor Decline
Error warrants small adjustment. If you weren’t paying close attention, you migh... Read more
Burn Treatment:
Don't Get Burned by 16000-16030 Missteps
Capture debridement pay with proper documentation. Whether from a sunburn in this new ... Read more
Reader Question:
Focus on PFSH for E/M Code Selection
Question: The surgeon’s office visit note indicates a comprehensive examinati... Read more
Reader Question:
Work This Plan for SNF Office Payments
Question: One of our surgeons is treating a skilled nursing facility (SNF) patient ... Read more
You Be the Coder:
Do This for Colonoscopy + Flex Sigmoidoscopy
Question: Our surgeon treated a patient with a temporary colostomy due to diverticu... Read more
CPT® 2016:
4 Tips Update Your IVUS Coding
Watch for codes that already include the service. Maybe you feel confused about how to... Read more
Coding Appendectomies:
Steer Clear of Red Flags That Could Thwart Your Claims
Don’t lose $241 with this one little mistake. Reporting appendectomies can be an... Read more
Practice Management:
Monitor Claims to Max Out Your General Surgeons' Pay
Keep your AR up-to-date. You’re up-to-date on coding changes, you’ve educa... Read more
Reader Question:
Check Global Days for Modifier Choice
Question: The definition of modifier 57 is “decision for surgery,” so w... Read more
Reader Question:
Find Method Code for Internal Hemorrhoidectomy
Question: Our surgeons recently started treating some internal hemorrhoids with &ld... Read more
Reader Question:
Ensure Valid Provider Signatures
Question: I’m having trouble getting my surgeons to sign their claim forms. S... Read more
You Be the Coder:
ICD-10 Must Tell Full Story for Bariatric Surgery
Question: When I’m billing for bariatric surgeries, I’m having problems... Read more
CCI 22.0:
Focus Your General Surgery Coding With This Edit Update
Expect bundles with most new 2016 codes. With 57,161 new edit pairs — roughly 40... Read more
CPT® 2016:
Implement Code Changes for Your Bronchial and Mediastinal Scope Cases
Pinpoint EBUS services with these codes. If your surgeon performs scope procedures in ... Read more
OIG Watch List:
Target Your EHRs for Scrutiny
Watch incentive payments, too. HIPAA enforcement just keeps getting tougher — th... Read more
Reader Question:
Age, Tunneling, and More Determine Catheter Code
Question: Our surgeon inserted a non-tunneled catheter for a three-year-old patient... Read more
Reader Question:
Master ICD-10 Burn Coding
Question: Our surgeon treated a patient at a subsequent visit for a second degree b... Read more
You Be the Coder:
Manage Your Lap Band Service Coding
Question: We had a patient who, following a lap band procedure, had a dilated pouch... Read more
GI Update:
Follow 5 Steps to Maximize Endoscopic Injection Pay
Watch for multiples. Your general surgeon might perform endoscopic injections to treat... Read more
Compliance:
Focus on Diagnoses to Make the Proper E/M Decision
You must document separate services and use modifier 25. A patient walks into the offi... Read more
CMS Update:
Use POS 19 for Off Campus Outpatient Hospital Services
Save POS 22 for on campus. As of January 1, you should have a new place-of-service (PO... Read more
Modifier 58:
Identify Intention for Staged Procedures
Unrelated services don’t count. Coding subsequent procedures during the post-op ... Read more
Reader Question:
Verify Breast Biopsy Procedure Location
Question: Can we report the technical component of breast biopsy services when we a... Read more
Reader Question:
Distinguish Hydrocele and Hernia Procedures
Question: If the surgeon repairs a reducible inguinal hernia and also excises a hyd... Read more
Reader Question:
Beware E/M on Vascular Surgery Date
Question: Our surgeon performed an endovenous radiofrequency ablation procedure thr... Read more
Reader Question:
Don't Drop 'Z' Code for Screening Colonoscopy
Question: Our surgeon performed a screening colonoscopy for a Medicare patient, but... Read more
You Be the Coder:
Go to 6th Digit for Crohn's in ICD-10
Question: I’m having trouble with the level of detail for Crohn’s repor... Read more
Integumentary Procedures:
4 Questions Focus Your Skin Substitute Graft Coding
Hint: Graft size doesn’t matter. If your surgeon treats burn victims, trauma pat... Read more
Medicare Physician Fee Schedule:
Beware 2016 Fee Changes That Could Slash Your Pay
Check out these steep endoscopy cuts. The Medicare Physician Fee Schedule (MPFS) final... Read more
ICD-10:
Results Are In--Few Glitches Reported So Far
CMS reports 90 percent claims acceptance rate. If your general surgery practice is exp... Read more
Reader Question:
Understand Hernia Details for ICD-10 Code Selection
Question: Our surgeon met with a 57-year-old patient complaining of severe pain around t... Read more
Reader Question:
Determine PFSH for E/M Choice
Question: I have a surgeon’s note for an office visit that clearly indicates a com... Read more
Reader Question:
Avoid ICD-9 and ICD-10 on Single Claim
Question: The surgeon admitted a patient at the end of September and completed the patie... Read more
You Be the Coder:
Account for Both EGD and Blockage Removal
Question: The surgeon performed an EGD with positioning and securing of jejunostomy tube... Read more