Choose your specialty from the list below to see how our experts have tackled a wide range of client questions.
Looking for something specific? Utilize our search feature by typing in a key word!
Bone Anchored Hearing Implants
What CPT code would I report for implanting a bone anchoredosseointegratedimplant with a magnetic transcutaneous attachment outside of the mastoid?
Question:
What CPT code would I report for implanting a bone anchoredosseointegratedimplant with a magnetic transcutaneous attachment outside of the mastoid?
Answer:
In 2023 three new CPT were created to report Transcutaneousosseointegratedimplants outside of the mastoid. For the implantation the code to report is 69729, for the replacement of the existing device report 69630 and for the removal of the implant report 69728.
*This response is based on the best information available as of 05/25/23.
E/M Coding Based on Time
When choosing the level of E/M we are confused about the History and Exam. If we choose a level of E/M based on time, does this time count toward total time, or is it only time spent on MDM?
Question:
When choosing the level of E/M we are confused about the History and Exam. If we choose a level of E/M based on time, does this time count toward total time, or is it only time spent on MDM?
Answer:
When choosing a level of E/M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.
Physician/other qualified health care professional time includes the following activities when performed:
- preparing to see the patient (e.g., review of tests);
- obtaining and/or reviewing separately obtained history;
- performing a medically appropriate examination and/or evaluation;
- counseling and educating the patient/family/ caregiver;
- ordering medications, tests, or procedures;
- referring and communicating with other health care professionals (when not separately reported);
- documenting clinical information in the electronic or other health record;
- independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and
- care coordination (when not separately reported).
source: CPT Assistant April 2022
*This response is based on the best information available as of 05/11/23.
Allergy Injections and E/M on the Same Date
We routinely bill allergy an E/M service when the patient comes in for allergy shots. Is that acceptable? Sometimes we bill 99211 if the nurse gives the injection and sometimes if the PA gives the injection 99212.
Question:
We routinely bill allergy an E/M service when the patient comes in for allergy shots. Is that acceptable? Sometimes we bill 99211 if the nurse gives the injection and sometimes if the PA gives the injection 99212.
Answer:
E/M visits should not be reported with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service. In that situation, report the E/M service with modifier 25 indicating that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided. If the only service provided is the allergy injection do not report an E/M service. Good documentation is key when reporting an E/M and allergy injections on the same date.
*This response is based on the best information available as of 04/27/23.
Allergy Treatment Coding
What CPT code do I use to report a vial test?
Question:
What CPT code do I use to report a vial test?
Answer:
There is no CPT code, nor should you charge, for a “vial test.” This is part of the vial provision code/activity (e.g., 95165) and not separately reported.
*This response is based on the best information available as of 04/13/23.
Glossectomy Coding Help
I have a question about glossectomies. When coding a glossectomy what needs to be documented? My physician just states in the operative report he performed a glossectomy. Is that enough?
Question:
I have a question about glossectomies. When coding a glossectomy what needs to be documented? My physician just states in the operative report he performed a glossectomy. Is that enough?
Answer:
The answer to your question is no. Glossectomy codes (41120-41150) require removal of a portion or all of the tongue not just the lesion. You must document what portion or how much of the tongue is removed and tongue tissue removal. If only a lesion is removed see CPT code(s) 41112-41114.
*This response is based on the best information available as of 03/30/23.
Adjacent Tissue Transfer
How should my physician document an adjacent tissue transfer? My physician documents the total in sq cm for the entire repair.
Question:
How should my physician document an adjacent tissue transfer? My physician documents the total in sq cm for the entire repair.
Answer:
The primary and secondary defect dimensions are required. The primary defect is the excision site and the secondary defect results from the flap design to perform the reconstruction. So documentation in the operative report must include:
- Primary defect-sq cm
- Secondary defect sq cm
- Primary defect sq + secondary defect sq cm=CPT code
*This response is based on the best information available as of 03/16/23.