Q: A physician performed a pleural catheter flush using saline with manual clearance of clots under ultrasound guidance. Should we bill an E/M code for an outpatient office visit or report this using other CPT codes?
Q: A patient presents for routine obstetrical (OB) care following a vaginal delivery. During the visit, the provider performs a postpartum depression screening. Should the depression screening be charged separately from the global OB visit service?
Q: Does a psychiatrist need to document a physical examination and a review of prescriptions in order to support the reporting of CPT code 90792 (psychiatric diagnostic evaluation with medical services)?
Q: If a patient comes in twice a day over the course of a week to receive an IV infusion of Vancomycin and the same line is used daily, would the coder report one initial infusion CPT code per day?
Q: The 2020 ICD-10-CM update added several new codes for legal interventions. What are these codes, and can they be assigned based on nonphysician documentation?
Q: Would it be appropriate to query the provider for clarification if documentation for an orbital fracture doesn’t specify the location of the fracture and whether it is open or closed?
Q: A patient presents to a wound care clinic for assessment of a 15 sq. cm open wound. A nurse evaluates the wound and performs selective debridement. Would it be appropriate to bill an E/M code and if so, should we report modifier -25?
Q: Suppose a patient comes in for psychological testing evaluation. The provider interprets the test results and patient data, prepares a report, and begins treatment planning. If the interactive feedback session is held several days later, how would this be reported using CPT codes?
Q: A clinician documented "combination Type 1 and Type 2, diabetes mellitus in poor control." This condition is sometimes called Type 1.5 diabetes. What is the correct ICD-10-CM code assignment for Type 1.5 diabetes?
Q: A physician orders a comprehensive metabolic panel and a quantitative blood sample to measure blood glucose level. How would a coder report these services using CPT codes, and what modifier would he or she use to indicate that the blood sample was performed separately from the panel?
Q: A patient presents to the ED seeking treatment for impacted cerumen affecting both ear canals. How would you report a bilateral cerumen removal using CPT codes?
Q: I was recently informed that providers use cellular-based tissue products to treat ulcers when a patient fails to respond to more conservative treatment options. What constitutes a failed response to treatment and how would this be documented?
Q: The American Medical Association added three new CPT codes for skin biopsies, effective January 1. What are the new biopsy codes and CPT guidelines for reporting them?
Q: A physician performs a hemiarthroplasty for a hip fracture. Would this procedure be reported with CPT code 27125 (hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty])?
Q: Can you bill CPT codes 76981 (ultrasound, elastography; parenchyma [e.g., organ]) and 76982 (ultrasound, elastography; first target lesion) at the same time as CPT codes for liver and breast ultrasounds?
Q: A lung cancer patient presents to the infusion clinic to receive chemotherapy treatments. The patient receives a Carboplatin infusion, a Gezmar infusion, and an Anzemet intravenous push. Which CPT codes would be used to report these services?
Q: What’s the difference between an incomplete miscarriage, a septic miscarriage, and a missed miscarriage and how would surgical treatments for these conditions be reported using CPT codes?
Q: I received confusing guidance regarding CPT coding for a segmental spinal fusion with pedicle screws placed at L3 and L4 vertebrae. Would it be appropriate to report CPT code 22612 with add-on code 22614 for this procedure?
Q: When is it appropriate to bill CPT code 77470 (special treatment procedure [e.g. total body irradiation, hemibody radiation, per oral or endocavitary irradiation]) for a special treatment procedure?
Q: A physician performs wound debridement on a patient’s right foot, then applies bilateral, multilayer compression dressings to each leg. How should this be reported?
Q: A patient presents to the emergency department with chest pain. The physician orders multiple services along with a subsequent infusion without a stop time. What CPT codes would be used to report these services?
Q: If a patient comes into an outpatient facility for a surgical procedure and the physician evaluates the patient before performing the procedure, can you append modifier -25 to the E/M service?
Q: A patient receives treatment for two ulcers, one on his foot and one on his hip. The physician performs a subcutaneous debridement to treat the foot ulcer and a muscle debridement to treat the hip ulcer. How would this be reported?
Q: If a patient is seen for a pressure ulcer on the foot related to diabetes, would you report a diabetes diagnosis code? If surgical debridement is performed and the patient receives treatment for their diabetes, can you charge for both an office visit and debridement?