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Subcutaneous vs Subfascial
If the provider says in their documentation that they went into the subcutaneous tissue and to the fascia to excise a 4 cm lipoma from the back, is this subfascial? This always trips me up when coding!
“Incident-to” vs “Direct” Billing
Our Nurse Practitioner saw a new patient (Medicare) in the office for evaluation of sinus complaints. He developed the plan of care. The patient was scheduled to follow up with the Nurse Practitioner. The patient returned to the Nurse Practitioner for a return visit with the same problem and no changes in the plan of care. Can he bill this “Incident to” the physician since it is an established patient with an established plan of care and the physician was in the office?
Appealing Intraoperative EEG/EMG Denials
I am new to coding for neurosurgery, and we are receiving denials for intraoperative EEG and EMGs; what documentation should we use for appeal?
Risk of Patient Management
Is a decision to NOT perform an injection with risk factors discussed “moderate” risk?
Ex: The patient has done 6 weeks of physical therapy for their spinal stenosis, which has provided some relief, but he is not at the treatment goal. We discussed performing a lumbar epidural steroid injection with the risks of the procedure, including bleeding, infection, and nerve damage. The patient is a diabetic, and we discussed the risks of the corticosteroid injection elevating blood glucose levels. After this discussion, he elected to continue PT and avoid injection at this time.
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?
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