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Kyphoplasty Coding
How do you report a kyphoplasty at 2 different spine regions, for example at T12 and L1?
Time
Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?
Date of Service
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Appendectomy with Cecum Resection
As part of an appendectomy, a portion of the cecum was involved and was included in the resection.. Can this be reported as a cecectomy?
Time Reporting for E/M Levels
My physician is billing office visits 99202-99215 based on time only. Is this best practice?
Established Patient: New Injury and Injection
We have a major hip and knee practice. We frequently see patients back for repeat injections; typically, we do not report the E&M, and report the injection only.
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