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?
Q: What are some tips for organizations that are just starting out capturing the type of information to report social determinant of health (SDOH) diagnoses in ICD-10-CM?
Q: A physician performs a lithotripsy on a stone in the ureter or removes a stone from the ureter through a transurethral approach, then performs a percutaneous nephrostomy and treats a stone in the kidney. Would both procedures be reported?
Q: A patient with a history of prostatic hypertrophy and dysuria receives a laparoscopic prostatectomy conducted with robotic assistance. Which CPT code would be used to report this?
Q: Which CPT code would be reported for an emergency department (ED) visit for an asthma patient experiencing exacerbated symptoms and released with a prescription for treatment?
Q: Would a same date admission/discharge E/M code be used for a scenario in which a patient is admitted at 11 p.m. on a Monday, is seen by the provider at 4 a.m. on Tuesday, and discharged at 8 p.m. on Tuesday?
Q: What are the differences between remote therapeutic monitoring and remote physiologic monitoring and what details should we look for in documentation to report these services with CPT codes?
Q: When is it permissible under Medicare to assign CPT add-on code 37186 for a secondary thrombectomy when an atherectomy is performed in the same vascular territory?
Q: What is the difference between “normal” and “abnormal” native connections in the descriptors for new 2023 CPT codes 33900-33903 describing percutaneous pulmonary artery revascularization by stent placement?
Q: For colonoscopies, is it appropriate in CPT coding to report the excision of several lesions in the same portion of colon separately if they are removed by the same technique?
Q: How do CPT codes 28295 (correction, hallux valgus, with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method) and 28298 (…; with proximal phalanx osteotomy, any method) differ?
Q: New ICD-10-CM codes for unspecified vascular dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety take effect October 1. Do these new codes require linkage and specific documentation by the provider that the conditions are related?
Q: We are getting some National Correct Coding Initiative (NCCI) edits for repeat laboratory services. What modifier do we use if a component of a panel test is repeated later?
Q: What is the best way to determine if an E/M service is above and beyond the physician work normally associated with a procedure to justify the use of modifier -25?