Q: How should we report services with modifier -50 (bilateral procedure) for physician claims when a private payer’s instructions contradict our Medicare administrative contractor (MAC)?
Artificial intelligence (AI) has burst on the scene with numerous clinical and coding applications for providers. This article looks at how the technology can be used and where human oversight is still required.
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
Q: A physician debrides a hyperkeratotic lesion on a patient’s left foot, second toe. During the same encounter, he performs a debridement of the five toenails. Which CPT codes and modifiers would be reported for this procedure?
Q: A patient underwent a diagnostic nasal endoscopy at 10 a.m. At 7 p.m., the patient developed an epistaxis and the physician had to use some complex cauterizing techniques to control the nosebleed. How would the physician’s services in this scenario be reported?
Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?
Q: One of our providers used a Jada device on a patient post-delivery, but I cannot find the corresponding CPT code. What is the CPT code for Jada device use?
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an E/M service level is based on medical decision-making (MDM)?
Q: Our coding department has a longstanding issue with physicians not presenting enough information to properly report CPT debridement services for ulcers, resulting in queries and denials. What do you recommend?
Q: What are some tips for organizations that are just starting out capturing the type of information to report social determinant of health (SDOH) diagnoses in ICD-10-CM?
Q: A physician performs a lithotripsy on a stone in the ureter or removes a stone from the ureter through a transurethral approach, then performs a percutaneous nephrostomy and treats a stone in the kidney. Would both procedures be reported?
Q: A patient with a history of prostatic hypertrophy and dysuria receives a laparoscopic prostatectomy conducted with robotic assistance. Which CPT code would be used to report this?
