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Is Documentation of HPI and Exam Necessary in Determining a level of E/M?
With the 2021 and 2023 Guideline changes, is it necessary to document an HPI and Exam when neither counts towards the level of service?
ENT Modifier 25
Does the following scenario meet the modifier 25, “significant, separate service” rules?
The patient presents with watery eyes, sinus, nasal congestion, and drainage. The physician evaluates the patient and does a nasal endoscopy to evaluate the upper airway further. The physician diagnoses the patient as having acute sinusitis and writes a prescription for an antibiotic. Instructions are given on taking the medications and following up if the patient has seen no improvement after 72 hours.
May we report an E&M-25 and the nasal endoscopy?
Two Surgeons, Same Practice, Co-Surgery?
I have a case where two surgeons from the same practice are reconstructing the abdominal wall following tumor resection. They each perform their own side of the component separation, surgeon A on the right and surgeon B on the left. Each surgeon dictated their own op-notes for the side they performed, and now they want to bill as co-surgeons. I’m unsure if this is appropriate, so I seek KZA’s advice.
Evacuation of recurrent subdural hematoma and drain placement
A patient returns two weeks after evacuation of a chronic subdural hematoma with a recurrence requiring another evacuation of the hematoma and placement of a subdural drain. What are the correct codes to report for the evacuation of the hematoma and placement of the drain?
Documentation for Endovascular Procedures
What information needs to be documented in the body of the operative report for endovascular procedures?
Adjacent Tissue Transfer
We are having some controversy in the office. Many of our physicians state the sq cm size of the primary and secondary defect combined is enough to support an Adjacent Tissue Transfer. Can you help?
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