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Evaluation and Management Service on the Same Date as an Office Procedure
A patient came into the office for a balloon sinus ostia catheterization and dilation of the maxillary, sphenoid and frontal sinuses bilaterally. My surgery scheduler has already obtained pre-certification for the procedure as it is covered in the office setting. I performed an examination and then did the procedure. I then performed a sphenoid, frontal, and maxillary dilation bilaterally. Can I bill an E/M service since I examined the patient?
Cancer Surveillance E/M
My physician saw an established patient for follow-up in the office for cancer surveillance. The patient is doing well and no treatment is indicated. In addition, the physician removes a benign lesion on the right anterior neck (1.1 cm) and the patient is being treated for a rash that is acute. The physician recommends cleansers and moisturizers and prescribes a topical steroid. What codes should be billed?
Muscle Flap Denial
We received a denial for a muscle flap. We appealed, and unfortunately, the denial was upheld due to the documentation. Can KZA provide some insight?
Free Nipple Grafts with Breast Reduction
In the setting of breast reduction, when free nipple grafts are done, is this separately reportable?
Erector Spinal Block with Discectomy
Our surgeon states in the procedure title “Fluoroscopic Erector Spinae Block (ESP) L5”. The documentation supports this as performed bilaterally at L5 prior to the surgical incision. Is this separately reportable?
Ablation of Thyroid Nodules
My physician performed a percutaneous radiofrequency ablation of 3 thyroid nodules, one in the lower part of the left lobe and 2 in the right lobe. I am not sure what CPT code I should report. Can you help?
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