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Specialty Coding - Articles

Use of binocular microscopy in the office
October 15th, 2015 - Mary LeGrand
Binocular Microscopy Question: Our physicians want to report binocular microscopy in addition to minor ear procedures when they use the microscope in the office. For example, removing ear wax or placing tubes, and mastoid debridements. Can binocular microscopy be reported in addition to the minor...
Visits outside the OB Global Package
July 27th, 2015 - Codapedia Editor
The CPT® book defines which services may be billed outside of the global OB package, and what services are included in the package. The start of the maternity care codes in the CPT® book describes the antepartum care services, including frequency and exam. The American College of...
Anesthesia and E/M services
June 1st, 2015 - Codapedia Editor
Anesthesia services are billed using CPT® codes 00100-01999. These CPT® codes are cross-walked to surgical codes. The crosswalk is available from the American Society of Anesthesiologists at Each anesthesia code has a base unit assigned to it. The anesthetist also bills the...

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Consult Documentation Guidelines
September 3rd, 2014 - Jeannie Cagle, BSN, RN, CPC
By Jeannie Cagle, BSN, RN, CPC For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · ...
Mini Mental Status Exam
October 1st, 2013 - Betsy Nicoletti
There is no CPT® code for the Mini Mental Status Exam. Physicians use the mini mental status exam (MMSE to test a patient's cognitive function. The test is made up of a set of questions, testing the patient’s memory, orientation and arithmetic calculation skills. There is a...
Coding for pulmonary services
August 28th, 2013 - Betsy Nicoletti
This is an overview of billing for services provided by Pulmonologists. Medicare recognizes Pulmonary Disease as a specialty. The resources section of this article contains the E/M Frequency data from CMS for the latest year available, and the fifty most commonly billed CPT® codes. What are...
Psychiatry code update
May 1st, 2013 - Codapedia Editor
I have attached a word document that you can print that explains the use of the new codes.
How do you report bilateral procedures? One line or two?
October 14th, 2009 - Mary LeGrand
Bilateral Total Knees—How to Submit the Claim From Question: How do I report bilateral procedures, one line or two? Answer: Great question, unfortunately the payors have made this simple concept of bilateral procedures challenging from a reimbursement standpoint! Survey your payors...
Transphenoidal hypophysectomy--how is this coded?
August 10th, 2009 - Kim Pollock
Question: How do we code a transphenoidal hypophysectomy when we do the procedure with an ENT doctor? The ENT doctor says he has his own codes to bill. Answer: There are two codes to report this procedure. First, CPT® 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or...
Chemotherapy Infusion and E/M on the same day
July 3rd, 2009 - Codapedia Editor
Is it appropriate to bill an E/M service with a chemotherapy infusion? Here is how Nancy Maguire answered that question: If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to...
May 11th, 2009 - Codapedia Editor
From the Q&A section: Question: I have a patient with a large (~15 cm) soft tissue mass in his flank which on initial evaluation is consistent with a large lipoma (95% sure, but I've been tricked with sarcomas before). For the excision, would I use the skin code (11406) or the...
Laparoscopic procedure without a code
May 11th, 2009 - Codapedia Editor
Do not use the open code for procedure when performing the service laparoscopically. Use an unlisted code if none exists. Contact your medical society and the CPT® committee to describe the service and advocate for a code. Here is Nancy Maguire's response to this question on the Q&A...
ROS Checklist
April 22nd, 2009 - Rikki Runyon
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ...
69210 Cerumen removal
April 19th, 2009 - Codapedia Editor
The CPT® Assistant clarified the rules for using code 69210 in the July 2005 newsletter. The key points for using this code: Ear lavage alone is insufficient: the ear wax must be removed by curette or instrumentation The billing provider must perform the service, not the nurse or...
How to submit a question to CPT® Assistant/AMA?
April 3rd, 2009 - Christina Benjamin
1. As a CPT® Assistant subscriber, if you have a question that is directly related to CPT® Assistant, they will answer it. Questions can be e-mailed to with subject - call for letters and to attention of Gloria Green per the CPT® Assistant. They ask that...
Using Modifer -59
March 31st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not...
Modifier 78
March 25th, 2009 - Codapedia Editor
Modifier 78 is used to indicate that the physician who performed a surgery which had a 10 or 90 day global period took the patient back to the OR for a related problem, typically, a complication. Do not use it for staged or related procedures--that is reported using modifier 58. For unrelated...
Modifier 79 Unrelated procedure or service
March 25th, 2009 - Codapedia Editor
Modifier 79 is appended to a procedure to indicate that the same surgeon took the patient back to the operating room during the global surgical period for an unrelated problem. The second procedure must be unrelated to the original procedure. See modifier 78 for return trips to the OR that are...
Performing only part of the global OB package
March 21st, 2009 - Codapedia Editor
The CPT® codes that describe obstetrical services start at 59000. There are codes for delivery that include the entire obstetrical package, from pre-natal, through delivery, to post-partum. These global codes are used when the practice performs all of the services. There are codes that...
Global obstetric package
March 21st, 2009 - Codapedia Editor
Payment for obstetrical services is packaged into a single payment when the physician practice provides all of the components of the service. There are CPT® codes for each component, however, when the practice needs to bill only part of the service. Physicians in a group of the same specialty...
Using modifier 66 (team surgery) Q&A
March 4th, 2009 - Mary LeGrand
General Surgery Multiple Surgeons, Different Procedures Question: Do I use modifier 66 (team surgery) when our General surgeon is operating on a child during the same session as a plastic surgeon doing a cleft palate repair or a urologist performing a urologic procedure such as a...
Anticoagulant management
March 3rd, 2009 - Codapedia Editor
In 2007, CPT® added two codes for anticoagulant management, 99363 and 99364. The codes are meant to be used by physicians and Non-Physician Practitioners (NPPs) who manage a patient's warfarin therapy on an outpatient basis, reviewing the PTINR, adjusting the patient's dosage as appropriate,...
Mental Health Medicare Co-insurance
March 3rd, 2009 - Codapedia Editor
Changes passed by Congress in the Medicare Improvements for Patients and Providers Act (MIPPA) in July of 2008 made an important change to how Medicare pays for mental health services. Unfortunately, the changes are not immediately effective. Currently, there is a 50% co-payment for most mental...
Teaching patients to use an inhaler or nebulizer
March 3rd, 2009 - Codapedia Editor
Use code 94664 when teaching patients how to use a nebulizer or inhaler. The CPT® definition is: Demonstration and/or evaluation of patient utlization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. The service may only be reported once/day. It is not a code defined...
Epley Maneuver
March 3rd, 2009 - Codapedia Editor
The Epley Maneuver is reported using code 95992. It is a per day code, and may not be reported with mulitple units in a single day. Audiologists and Physical Therapists may report this service. The CPT® definition of the code is: Canalith repositioning procedure(s) (eg Epley Maneuver, semont...
AAA screening
March 2nd, 2009 - Codapedia Editor
Medicare allows screening for Abdominal Aortic Aneurysm in very limited situations. The screening must be ordered as part of the patient's Welcome to Medicare visit (Initial Preventive Physical Exam). That limits the screening to newly enrolled Medicare patients. If the patient has not had the...
Operating microscope
March 2nd, 2009 - Codapedia Editor
CPT® defines certain operative procedures as including the use of an operating microscope, code 69990. 69990 is an add on code, indicated by the plus sign in front of it in the CPT® book. It is billed as a second procedure, without modifier 51. At the start of the section about this code...
Pessary billing and coding
March 2nd, 2009 - Codapedia Editor
Both CPT® and the American College of Obstetrics and Gynecology (ACOG) instruct us to use 57160 for the fitting and insertion of a pessary the first time the service is provided. Removing, cleaning and reinserting a pessary is part of an evaluation and management service and should not be...
Initial OB Visit
March 2nd, 2009 - Codapedia Editor
Physician practices who provide OB services often want to know if they can bill separately for the first OB visit, or if it is part of the global package. The short answer is: once you begin the OB service, it is part of the package. Prior to home pregnancy tests, many patients came in to see if...

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