Question: Can we bill code 57160 when a patient comes in for a pessary cleaning? Answer: No, report an E/M service based on the key components. 57160 is for the initial fitting and insertion of the pessary. Read this post for more information about pessary billing and coding. See more Everyday Coding Q & A's Related Resources: Key Components of E/M Services, Pessary Billing and Coding … [Read more...]
Everyday Coding Q&A
You have questions, we have answers. Everyday Coding Q&A is a brand new feature of CodingIntel. We will be taking the questions we receive from you and posting answers on a monthly basis. Do you have a question whose answer would benefit fellow physicians, coders, or staff as well as yourself? Send it to firstname.lastname@example.org.
Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining factors? Answer: Not according to CMS. Recently, when I was explaining the two of three rule to a physician, he said, “Just like the Meatloaf song.” I hadn’t ever considered Meatloaf and the Documentation Guidelines together. Medical necessity and the nature of the presenting problem need to be considered … [Read more...]
Question: When my doctor personally performs moderate sedation of 15 minutes, does he/she need to document the time in the record? Answer: Yes. Without documentation of the actual time, you can’t confirm that the doctor met the threshold of time needed to bill the code. That is, how do we know there was at least 8 minutes of time spent? According to the CPT rule pertaining to time, from the current CPT book, “A unit of time is … [Read more...]