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    Wiki How do you bill for non-covered services?

    There are a lot of nuances about why a procedure isn't covered. There are also a lot of nuances in your insurance contract about when you cannot bill a patient, and the specific requirements when you do bill a patient. Something that is not covered because insurance includes it in the work of...
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    Wiki ATTN CPC-A

    Yes, that is a great reason to do Practicode, especially if you do not have healthcare related experience to pull from. However, I often see others complaining that Practicode was a waste of time and/or money because they believe it counts as experience. They incorrectly believe they will then...
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    Wiki Preventive care with an E/M

    If all the provider did was say "hey, that mole looks odd - go see a derm", my opinion is that does not meet the requirement to bill a separate E&M with -25.
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    Wiki Other opinions

    Whenever trying to determine an E&M level, you need to determine the level of each component of overall MDM: problem, data and risk. You must have at least 2 of those at a specific level to reach that overall level. Alternately, you may bill base on time. My 2 second review indicates this...
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    Documentation Insurance/Cosmetic

    You should get official compliance or legal advice on this. However, I will weigh in with my opinion. It is typically not "required" to have separate notes. Doing so does make a gray area much more black and white. Let's use an example of a worker's comp patient presents for hitting his...
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    Wiki Medicare Annual Exam

    If no problems are being addressed, and patient is receiving a cervical/breast cancer screening, then G0101 would be appropriate. If they do require a PAP, then also Q0091. If a full preventive visit is performed, then 9938x-9939x are appropriate. Remember that G0101 & Q0091 are covered every...
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    Wiki Inpatient Initial E&M

    Ortho definitely not my wheelhouse, but I would think this is more than low for acute, uncomplicated illness. I would consider a fracture in a younger, healthier patient, or a non-displaced fracture to be acute, uncomplicated. I would likely consider this problem acute, complicated as they...
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    Question iud insert with cervical block

    I am not aware of any carrier that does not consider blocks part of the procedure when performed by the physician providing the primary service. This AAGL article specifies: Anesthesia CPT Codes: All anesthesia, local or regional, is considered integral to the procedure so cannot be billed...
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    Wiki New E/M codes reimbursement

    I know you already came up with an answer, but did want to make you aware that discussion to determine charges is something that is actually prohibited. And allowables (except for Medicare/Medicaid) are determined by your insurance contracts. So my allowable for 98000 by a particular payor is...
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    Wiki Insight on billing 59425 and 59426 codes.

    You can check their policy more carefully than I did, but at a glance I did not see this required. I'm in NY and have zero experience with Wellpoint TN. I know for our carriers, we typically bill out the 59425/59426 with the date of last treatment, not a range.
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    Wiki iud insert and rem same day

    I agree with Corinne. The removal was required for the provider to correct their initial mis-placement. In fact, while looking for a reference on a totally unrelated question, I came across this AAGL article which states: Difficult Insertions/Failed Insertions CPT Codes: Modifier 22 can be used...
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    Billing a Post-Op for a provider that changed Offices

    It doesn't matter who employed the physician at the time. The surgery was paid which has a 90 day global. Any work that is part of the global surgical package was already paid when the surgery was paid. The same guidelines apply to new vs established patient.
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    Wiki Insight on OB Antepartum only billing of 59425 and 59426

    Any questions should be posted only once, in whatever the most appropriate forum is. I answered this in your other post. https://www.aapc.com/discuss/threads/insight-on-billing-59425-and-59426-codes.201672/
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    Wiki Insight on billing 59425 and 59426 codes.

    From my experience, anytime a carrier accepts global maternity billing, it can be a challenge when billing needs to be split. If you provided some/all antepartum care, but did not deliver, then 59425 or 59426 could be appropriate. However, if another provider also billed for global, or a...
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    Wiki BCBS 2025 Telemedicine Policy

    Every carrier makes their own guidelines about whether or not telemedicine is covered and how it should be billed. If they already provided guidance to follow their current policy that is what I would recommend.
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    Wiki E/M coding question

    If the physicians are different specialties, I would code each visit for each clinician based on the documentation of that specific clinician.
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    Wiki Modifiers JW and JZ

    JZ & JW are potentially appended to the medication (J-code) if a single use vial. You would have to check if the J-code you are injecting is single use and requires JZ/JW.
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    Wiki Bill Modifier 59 to an E/M code

    I (and another member) answered in your original post https://www.aapc.com/discuss/threads/billing-modifier-59-to-an-e-m-code.201652/ Any questions should only be posted ONCE in whatever the most appropriate forum is.
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    Wiki Billing Modifier 59 to an E/M code

    Time to pull out the Medicare global surgery booklet reference (a personal fave :geek:): https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf If the carrier follows Medicare's definition of global surgical package, a follow up for a complication that does not require a return...
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    Wiki Bill E/m visit for preop during global

    "To make sure everything is OK" is a little to vague to definitively state either way. If the physician already made the decision for the surgery, and the patient is coming in just to go over instructions again, then I would consider this part of the global package. If the physician is...
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    Wiki Telehealth Billing- Student out of state- MD in Massachusetts

    This is a legal question and should be addressed accordingly, but most states require a physician practicing medicine in their state to be licensed in their state. If the physician is not licensed for where the patient presently is located, I would not suggest providing services. You have to...
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    Wiki Vasectomy Consults

    With any service, you should level the visit based on the documentation for the individual patient at this specific encounter. Patient1 could be young and healthy with nothing else going on and could be a different level than Patient2 who is diabetic, hypertensive, and requires a discussion...
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    Wiki HOW TO BILL FOR A CERTIFIED NURSE PRACTITIONER SURGICAL ASSIST

    The claim for the assistant will go under the NP's name & NPI as a separate claim from the primary surgeon. The appropriate modifier for NP/PA/CNS assisting at surgery is -AS not -SA. 1) The procedures must allow an assist. 2) The documentation must indicate who the assist was and briefly...
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    Wiki New Provider Billing Global Maternity

    This would be a decision of the payor, but I've never heard of such a policy. Particularly with an OB group, patients often see multiple providers in the group as you don't know who will be on call when patient goes into labor. I would reach out to your payors for confirmation.
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    Wiki G2211

    G2211 may be billed to any carrier, and it is not incorrect coding to use it. HOWEVER, some commercial carriers may have a policy that bundles it with the E&M service. That does not mean it was not appropriate to code. We bill to all payors.
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    Question Audio only visits for less than 5min

    If the carrier wants audio-only billed with the new code set 98008-98015, there must be a minimum of 10 minutes of medical discussion. There is currently no CPT which matches your scenario. **IF** the carrier wants audio-only billed with 99202-99215 with modifier -93, those codes may be...
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    Wiki Discontinued Laparoscopic Hysterectomy

    A third vote for 58661-50. If documentation supports extra work in first trying to removed the uterus, consider -22 as well.
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    Wiki ATTN CPC-A

    I definitely agree with Pam. If an employer requires experience, Practicode does not replace required experience. To me, any related job where you could interact with clinicians, patients, payors, coders, billers, front desk, administrative personnel, etc., will all make you a more well...
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    Wiki What coding certification would you recommend.

    Definitely another voice to agree with the above. IF you wish to expand your knowledge AND there is an area that specifically interests you, then consider getting that additional certification. You should view it as - I'm getting another certification because a particular specialty, or type of...
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    Wiki Telehealth visits and modifier for 2025

    There was Congressional action. However, at the present time it simply extends coverage until 03/31/2025. I expect it will be extended past that (hopefully on a permanent basis), but only Congress may do so.
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    Wiki EXCISION OF VULVAR LESIONS

    Yes. I am not clinical by any standard, but my understanding is depending on the amount of tension in the area being excised, and how they are processed, some will minimally shrink, and some can significantly shrink. https://pubmed.ncbi.nlm.nih.gov/34459559/
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    Wiki Doc gave injections during NP visit

    Depending on the scenario, there are a few options: 1) Scenario 1 - NP evaluated hand issue AND also a knee problem. Discussed with MD who gave the CMC joint injection. MD documents they personally performed the injection and signed record: E&M -25 with both dx under NP Injection with hand dx...
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    Wiki EXCISION OF VULVAR LESIONS

    They document as length x width x depth. So 2x3x2 cm is 2cm long, 3cm wide and 2cm deep. I'll add I have an issue with the "approximately" before the size. Approximately 3cm could mean 2.9cm which is a different code than 3.1cm. I instruct my clinicians that the coders need to know the exact...
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    Wiki Escalation of hospital level of care

    I would not consider ordering a consult by another specialist, increasing the oxygen, or adding a medication as "escalation of hospital level of care." Regarding transferring to a nursing facility, acute recovery unit or SNF. If the patient was prior in a higher level of care, I would not...
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    Wiki What qualifies a unique test

    I agree. One CPT = one data point.
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    Wiki has anyone billed for restraints

    Not my wheelhouse, but I'm not certain I understand the question. Who/why would be coding for restraints?
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    Wiki Open or laparoscopic supracervical hyst

    When a procedure is planned and/or starts as one approach, but is completed by another approach, you code how it was completed, not how it was intended or started. This would be coded as open. Make sure to add as a secondary diagnosis for laparoscopic converted to open.
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    Wiki 38571-52 & 38570-59 Billable combination?

    Melanie makes a bunch of great points above. FYI - SGO typically does a pretty good job with coding advice, but that doesn't mean I've never seen clearly incorrect (or outdated) information from them. Different payors, different coders, different healthcare systems could have opposite opinions...
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    Wiki Signature Question

    That is how I am interpreting. In the link you provided, just above the bullet list, you left off the sentence "The connection may be evidenced by:" So co-signature is one way of supporting incident-to.
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    Wiki Mid level Service Providers (PA)

    If ALL claims have been denied, I would imagine there is an issue with the way you are submitting, or with her provider enrollment. Once you figure out why they are denied, you can delve further. Yes, ACPs receive 85% reimbursement from Medicare for professional services. The supervising...
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    Wiki modifier 53 used by physician for discontinued surgery at ASC

    That statement refers to the hospital/facility billing. The advice by @MGable1018 also refers to the facility billing. I am not aware of any reason -53 would be invalid for the physician's surgery claim. When billing -53, many carriers will request the medical records and/or a letter of...
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    Wiki UPT for Acutane- Mismatch gender

    Look at modifier -KX. From CMS: For Part B claims processing, the KX modifier shall be billed on the detail line with any procedure code(s) that are gender specific. The definition of the KX modifier is: Requirements specified in the medical policy have been met. Use of the KX modifier will...
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    Wiki Intergy through Greenway Experience?

    I used for about 15 years, but I haven't used since 2018, so I'm not sure how relevant my tips would be. I had 2 real negative experiences, but both were essentially with the company rather than Intergy. 1) After using the system for years, we paid way too much for their consultant to travel...
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    Wiki Help please Hernia codes driving me insane

    49595 Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible...
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    Wiki Help verifying correct billing for In-hospital by non-hospital provider

    The work performed by a physician (even if the patient is admitted) is billed under the physician to Part B as professional fee services. The hospital facility services (room & board, nursing work, etc) is billed by facility under Part A.
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    Wiki Exploratory laparotomy, right ovarian cystectomy, omentectomy, peritoneal biopsies, lysis of adhesions, removal of prior scar - only 58925?

    Agree this is 58925. I would feel comfortable with -22 (even without time) based on the additional work documented (uterosacral ligament biopsy, LOA, omentectomy. However, an extra sentence or 2 can make your -22 case black and white instead of dark gray.
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    Wiki Practicode vs actual experience

    I do not know of any hiring manager that considers Practicode the equivalent of real world experience. I personally consider it additional training/education. Practicode may help you stand out from other CPC-As, but if a job requires 1 year of experience, Practicode will not waive that. My...
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    Wiki G2211 w/pbb

    There is certainly scant official advice on requirements of G2211. If the physician is only performing and billing for an E&M service 99211-99205, G2211 could be appropriate to add if they are longitudinally managing the complex condition.
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    Wiki removal of foreign object genitalia- No Incision? CPT Code or included in E/M?

    Not my area of expertise, but is this situation that the provider removed a BULLET from the SCROTUM without making any incision? If so, I would consider 55120-52 or unlisted, leaning toward unlisted.
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    Wiki Telehealth out of state

    Telehealth across state lines is a sticky situation as each state determines the specific licensing requirement. In your situation, it sounds like this is NOT across state lines. The provider and the patient are currently located in the same state. As long as the provider has a medical...
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