Medical Coding Guide - Learn How to Code

CPT code 20561 : Unknown Coding tips

June 19, 2024June 19, 2024 Jitendra M.Sc CPC

Basics of CPT code 20561 In this exam, the physician inserts a dry solid filament needle through the skin and into one or two muscles in CPT code 20560 and into three or more muscles in CPT code 20561. Indicated for myofascial pain relief and movement impairments, trigger points (focal, discrete spots of hypersensitive irritability identified within bands of muscle) are often the target of insertion. These points cause local or referred pain and may be formed by acute or repetitive trauma to the muscle tissue. This procedure, also known…

CPT code 99395 : Best Coding tips

June 19, 2024June 19, 2024 Jitendra M.Sc CPC

Basics of CPT code 99395 Periodic comprehensive preventive medicine services are typically well-patient examinations for established patients presenting for reevaluations and/or management of overall health condition with code selection dependent upon the patient’s age. These services include applicable patient history and examination, guidance/recommendation regarding personal risk factors, and any laboratory and/or diagnostic procedures ordered. Clinicians are not required to report minor or self-limiting problems or complaints noted during the course of the preventive examination when those problems do not require any additional work or necessitate performing the key components of…

Aortography, Cholecystectomy & Angioplasty/Stent placement Coded Reports

June 13, 2024June 13, 2024 Jitendra M.Sc CPC

Sample Coded Report 1 Pre-op Diagnosis: Peripheral vascular disease, unspecified (CMS/HCC) Post-op Diagnosis: Severe left SFA stenosis with only moderate right SFA atherosclerotic stenosis Procedure(s): Bilateral – Angiogram Extremity Bilateral Proc. Description(s) & CPT Code(s): Angiogram Extremity Bilateral: Anesthesia: Procedural Sedation Estimated Blood Loss: Minimal Quantitative Blood Loss: No data recorded Drain: None Total IV Fluids: mL Specimens: No specimens Complications: Read also: Coding guide for CPT code 64400-64448 ( nerve injection procedures) Superb tips for CPT code 37246, 37247, 37248 and 37249 Superb guide for CPT code for Myelogram Findings: Left 80% focal distal SFA stenosis with…

Sample Coding Report for 36903 CPT code (AV fistulogram with stent)

June 11, 2024 Jitendra M.Sc CPC

Pre-op Diagnosis: Stenosis of the proximal arteriovenous fisutla Post-op Diagnosis: Same as Pre-op Procedure(s): Left – Arteriovenous Fistulogram with angioplasty and stent graft placement Proc. Description(s) & CPT Code(s): Arteriovenous Fistulogram: Anesthesia: Procedural Sedation Estimated Blood Loss: Minimal Drain: none Total IV Fluids: minimal Specimens: No specimens Complications: none Disposition: aroused from sedation, and taken to the recovery room in a stable condition Condition: doing well Anesthesia: Monitored Local Anesthesia with Sedation Anesthesia start time:06:59 Anesthesia stop time: 07:37 Read also: Coding guide for AV fistual CPT code 36901 Coding guide for Stent placement in AV fistulat Anesthesia Meds Versed:1 mg Fentanyl:50 mcg Anesthesia Protocol in…

Cpt code 36471 & 36478 Coding tips

June 4, 2024June 7, 2024 Jitendra M.Sc CPC

When to use CPT 36478 and 36479 The physician uses percutaneous, laser, endovenous ablation therapy to treat venous incompetence in an extremity vein. Laser energy is used to heat the vein and seal the vein closed. The most common site of treatment is the greater saphenous vein. The procedure includes any imaging guidance and monitoring. The leg is prepared and draped and a local anesthetic is applied to the puncture site. A needle is inserted into the access site. A guidewire is placed into the vessel using ultrasound guidance. An…

Coding guide for CPT code 58300 (IUD device placement)

June 2, 2024June 7, 2024 Jitendra M.Sc CPC

Coding description for CPT code 58300 The physician inserts a speculum into the vagina to visualize the cervix. A tool is used to gently pull down the cervix; it is dilated. For CPT code 58300, an intrauterine device (IUD), any of a variety of shapes (coil, loop, T, 7), is guided into the uterus through an insertion tube placed in the cervical os. In code 58301, to remove a previously placed IUD from the uterus, a device is inserted through the cervical os and used to grasp and remove the…

Avoiding Common Mistakes in Dual Surgeon Coding with 62 Modifier

May 28, 2024June 16, 2024 Jitendra M.Sc CPC

Basics of 62 Modifier When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by submitting CPT modifier 62. Each surgeon should report the co-surgery once using the same procedure code. Do not submit this modifier for assistant at surgery services like HCPCS modifier AS and CPT modifiers 80, 81 and 82. This modifier may only be submitted with surgical codes. Documentation must be submitted upon request, or you may submit documentation with your initial claim,…

Minor & Major Difference between 25 and 57 modifier

May 26, 2024May 26, 2024 Jitendra M.Sc CPC

We know that their are set of modifiers used for E/M codes for any related or unrelated services performed on the same date of service (DOS). But still many medical coders are not aware when to use these set of modifiers depending on the procedures (major or minor) performed on same DOS. Today we will learn when to use the modifier 25 and modifier 57 when a minor or major exam is performed with E/M visit. Before going ahead let us see the description of both modifiers below. 25 modifier–…

Coding tips for CPT code 22310

May 20, 2024June 6, 2024 Jitendra M.Sc CPC

Fracture/Dislocation Treatment Definitions ( CPT code 22310) In the Musculoskeletal System subsection of the Surgery section in the CPT 2024 code set, “closed treatment” is defined as follows: The treatment site is not surgically opened (ie, not exposed to the external environment nor directly visualized). Closed treatment of a fracture/dislocation may be performed without manipulation (eg, application of cast, splint, or strapping), with manipulation, with skeletal traction, and/or with skin traction. CPT Code 22310 describes closed treatment of a vertebral body fracture without manipulation. Typically, a brace or other device…

Vascular Surgery Sample Coded Charts

May 16, 2024 Jitendra M.Sc CPC

Medical coding Sample Coded Report 1 Pre-op Diagnosis: Nodular sclerosis Hodgkin lymphoma of lymph nodes of multiple regions (CMS/HCC) [C81.18] Post-op Diagnosis: Same as Pre-op Procedure(s): Right – VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT – Wound Class: Clean Proc. Description(s) & CPT Code(s): VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT: Anesthesia: General Estimated Blood Loss: Minimal Quantitative Blood Loss: No data recorded Drain: None Total IV Fluids: 100 mL Specimens: No specimens Complications: none Findings: tip of catheter at atriocaval junction Technique: Patient was brought to the operating room and placed…