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2021 Evaluation and Management Codes: Is a History Required?
My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me.
Question:
My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me.
Answer:
You are wise to ask because that’s not exactly true. It is correct that the History will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that you will document a “medically appropriate” (per CPT™ history for each encounter.
*This response is based on the best information available as of 06/30/22.
Billing for Intestinal Tear During Enterostomy Closure
While performing a cholecystectomy a tear in the small bowel was made during extensive lysis of adhesions. Can repair of this injury be billed in addition to the cholecystectomy? It was unavoidable since it was the consequence of the extensive lysis required?
Question:
While performing a cholecystectomy a tear in the small bowel was made during extensive lysis of adhesions. Can repair of this injury be billed in addition to the cholecystectomy? It was unavoidable since it was the consequence of the extensive lysis required?
Answer:
Although the tear was unavoidable, the repair would not be separately billing. It is still be considered an iatrogenic (inadvertent or accidental) procedure.
However, if documentation supports the increased difficulty during the procedure (including documentation of time spent in addition to the usual time for the procedure), then a modifier 22 may be indicated.
*This response is based on the best information available as of 06/16/22.
Billing for ICG Dye
The surgeon did a robotic/laparoscopic cholecystectomy and cholangiogram with ICG and firefly identification of biliary anatomy. He billed a 47563. Can he can bill separately for the icy green and firefly dye?
Question:
The surgeon did a robotic/laparoscopic cholecystectomy and cholangiogram with ICG and firefly identification of biliary anatomy. He billed a 47563. Can he can bill separately for the icy green and firefly dye?
Answer:
Billing for indocyanine (ICG) or Firefly TM fluorescence is bundled into 47563 laparoscopic cholecystectomy with cholangiogram and is not separately billable.
*This response is based on the best information available as of 06/02/22.
Confusion About New 2021 E/M Guidelines
The new guidelines that are coming out in 2021 for all types of E/M services, right?
Question:
The new guidelines that are coming out in 2021 for all types of E/M services, right?
Answer:
No. The new guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the current guidelines for all other E/M services, even consultations in the office.
*This response is based on the best information available as of 05/19/22.
Abdominal Fat Pad Core Biopsy
We did an abdominal fat pad biopsy for primary cutaneous Amyloidosis. Would 49180 or 11104 be the appropriate code for this?
Question:
We did an abdominal fat pad biopsy for primary cutaneous Amyloidosis. Would 49180 or 11104 be the appropriate code for this?
Answer:
49180 is for a core sample within or behind the abdominal cavity. If the core biopsy is documented down to the subcutaneous fat pad only, this is coded as a punch biopsy 11104. And if the provider documents ultrasound guidance with proper documentation (i.e., noting anatomical findings and needle placement), 76942 can be billed as well with modifier 26 if indicated.
*This response is based on the best information available as of 05/05/22.
Coding a Hand Assisted Laparoscopy
The surgeon described the procedure as a ‘hand assisted laparoscopy”. He brought part of the bowel outside of the body for evaluation. Does this convert the procedure to open?
Question:
The surgeon described the procedure as a ‘hand assisted laparoscopy”. He brought part of the bowel outside of the body for evaluation. Does this convert the procedure to open?
Answer:
Mobilizing the bowel outside the body (extracorporeally) during a laparoscopic procedure does not convert the procedure to open, it is still considered a laparoscopic procedure and coded as laparoscopic.
*This response is based on the best information available as of 04/21/22.