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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?
Piriformis Muscle Injection
We perform Piriformis muscle injections in the office under ultrasound guidance, what code should we be reporting for this service?
Submucosal Repair with Lateral Wall Implants
What code do I use for a unilateral repair of a nasal valve collapse with submucosal wall implants on one side?
Sphenopalatine Ganglion Block
How do I report a ganglion impar injection of Depo-Medrol and Lidocaine?
Diagnosis Coding Excludes 1 Codes
Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.
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