Please see the Telemedicine article for the rules and guidelines for use during the COVID-19 public health emergency. Medicare covers some services performed via real-time audio and video between a patient in an underserved area and a physician or other practitioner who is not in the same place as the patient. Requirements for Medicare telehealth […]

Question: What are the review of system requirements when an annual physical (99381-99387, 99391-99397) is performed/billed by an OBGYN practitioner? Answer: These codes were revised in 2002, and CPT® stated that comprehensive as defined in the Documentation Guidelines doesn’t apply to comprehensive in these codes. In fact, the Documentation Guidelines never mention preventive services. The […]

There are several factors to consider when coding for destruction of benign and pre-malignant lesions. Let’s begin with a definition. From the CPT® book: “Destruction means the ablation of benign, premalignant or malignant tissues by any method, with or without curettement, including local anesthesia and not usually requiring closure.” Start with location Mouth, eyelid or […]

Some Evaluation and Management codes, and some other codes are defined by the amount of time of the service. This article reflects the rules for using time in the 1995 and 1997 documentation guidelines, for all E/M services. In 2021, how to use time for office visit codes 99202-99215 will change. This article does not […]

Now that the dust has settled from the release of the Physician Fee Schedule Final Rule, maybe it’s time for a re-cap.  This article will also discuss CodingIntel’s survey results.  Thank you for taking the time to complete the survey. CMS postponed the most radical, jaw dropping proposals. In fact, CMS said that it would […]

Skin lesion excisions are reported using codes from the integumentary section: Excision of benign lesions: 11400—11471 Neoplasms Cicatricial (scars) Fibroma Cutaneous lipoma Inflammatory lesions Congenital lesions Cysts Excision of malignant lesions: 11600—11646 Neoplasms of skin (e.g., basal cell CA, squamous cell CA, melanoma) Key points Select the code based on the size of the excision, not the […]

Question: I’ve been trying to figure out what the difference is between CPT® codes 99446 and 99451.  I finally found this in re-reading your article.  Is this the only difference between these 2 codes? For 99446, 99447, 99448, 99449, if greater than 50% is in data review and/or analysis, do not bill those codes; according […]

Question: My question is regarding Anticoagulation Management Code 93793. Guidelines state that this code can be performed by a physician, NP, or PA. My question is, if clinical staff performs the service in the doctor’s office setting, can code 93793 be billed under the supervising physician’s name? Clinical staff: Sees the patient face to face […]

The most common use of modifier 58 in dermatology is for re-excision of a lesion because the margins weren’t clear, based on the pathology report. Benign and malignant excisional biopsies have a 10 day global period. If the patient returns for a re-excision, the same code may be reported again, or a code for a […]

Accurately documenting and coding E/M services is critical to reducing compliance risk and maximizing revenue for the evaluation and management services your practitioners provide. This guide is specific to documenting and coding E/M for dermatology. History Component for Dermatology E/M services Definition History is one of the three key components (history, exam, and medical decision […]