Minor Surgical Procedures
When performing minor surgical procedures, it is important to document what was done, how it was done, where it was done, why it was done, how deep, how long, and how many.
In billing and reporting a procedure, document in the medical record the key components of the procedure as described by the CPT® book. If the CPT® book defines the code as centimeters, document how many centimeters long the lesion was. If the CPT® book defines the code as each, document how many. If it describes...
Subsequent hospital visits
Hospital services are all defined by CPT® as per day codes, that is, all of the care provided to a hospitalized patient during the calendar day. If a physician (or that physician's covering partner of the same specialty) sees the patient a second time during the calendar day, a second visit is not submitted. (See the articles on critical care and prolonged services for a description of when those services are reportable.)
The subsequent hospital visits (99231--99233) are defined...
Family meetings without the patient present
Medicare does not permit a physician practice to bill for family meetings without the patient present. The physician may not bill Medicare, nor may they bill the family member. It is fairly common for the spouse or child of a patient to ask to see the physician to discuss the patient's care. The meetings can be quite lengthy and involve a lot of physician time. For Medicare, however, unless the patient is present, there is no payment for the service.
You may not bill the...