Q: How would a coder report the scenario of an unmedicated diabetic patient with diabetic renal nephrosis and out-of-control blood sugar during an encounter?
Lynn Anderanin, CPC, CPB, CPMA, CPC-I, CPPM, COSC , covers FAQs she has received, specifically about CPT reporting for arthrodesis, acromioplasty, arthroplasty, arthroscopy, and spinal decompression procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Lynn Anderanin, CPC, CPMA, CPPM, CPC-I, COSC , answers frequent questions she receives from providers pertaining to physician coding for CPT orthopedic services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: How should we report services with modifier -50 (bilateral procedure) for physician claims when a private payer’s instructions contradict our Medicare administrative contractor (MAC)?
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
Q: A physician debrides a hyperkeratotic lesion on a patient’s left foot, second toe. During the same encounter, he performs a debridement of the five toenails. Which CPT codes and modifiers would be reported for this procedure?
Q: A patient underwent a diagnostic nasal endoscopy at 10 a.m. At 7 p.m., the patient developed an epistaxis and the physician had to use some complex cauterizing techniques to control the nosebleed. How would the physician’s services in this scenario be reported?
Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?
Q: One of our providers used a Jada device on a patient post-delivery, but I cannot find the corresponding CPT code. What is the CPT code for Jada device use?
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an E/M service level is based on medical decision-making (MDM)?
Q: Our coding department has a longstanding issue with physicians not presenting enough information to properly report CPT debridement services for ulcers, resulting in queries and denials. What do you recommend?
