Clearing Up the ERCP and Cholangioscopy Coding Confusion

There is a common misconception that CPT® add-on code +43273 for cholangioscopy can only be reported when using a SpyGlass™ scope. After conducting research, I can confirm that this is not accurate, and here’s why. Focus on the Procedural Note Endoscopic retrograde cholangiopancreatography (ERCP) involves both diagnostic and therapeutic approaches, with distinct techniques covered under … Read more

Steps for Accurate Coding of Complex Surgical Procedures

Medical coders often face the challenge of decoding complex surgical reports filled with specialized terminology and detailed procedures. When confronted with a lengthy, intricate report, it can be overwhelming. However, breaking the process into manageable steps helps simplify and organize the task. The following six steps will guide you in transforming a complex surgical procedure … Read more

Mastering Fracture Treatment Coding: A Comprehensive Guide for Accurate ICD-10-CM and CPT Billing

Mastering Fracture Treatment Coding: A Comprehensive Guide for Accurate ICD-10-CM and CPT Billing

For accurate ICD-10-CM and CPT coding of fracture treatments, medical coders should identify the following critical details from the physician’s documentation: Fracture Location and Laterality: Specify the anatomical location (e.g., distal, proximal, mid-shaft) and laterality (if applicable) of the fracture. Common anatomical terms include distal, middle, proximal, mid-shaft, apophyseal, articular, periarticular, and others. Traumatic vs. … Read more

Proper Code Selection for Incision and Drainage (I&D) CPT code Procedures

Proper Code Selection for Incision and Drainage (I&D) CPT code Procedures

Basic of Incision and Drainage (I&D) CPT code Procedures Accurate code selection for Incision and Drainage (I&D) procedures is essential for proper reimbursement. I&D is a common surgical intervention used to treat infections such as abscesses, cysts, and boils. This procedure involves making an incision in the affected area to allow the drainage of infected … Read more

CPT code 35840 Coded Sample Medical report

PREOPERATIVE DIAGNOSIS: 1. Suspected abdominal wall abscess POSTOPERATIVE DIAGNOSIS: 1. Abdominal wall abscess PROCEDURE: 1. Exploration of abdominal wall post op fluid collection, incidion and drainage of abdominal wall abscess ANESTHESIA: General INDICATION FOR PROCEDURE: This unfortunate 63y.o. lady underwent free flap reconstruction of her left arm wound with an abdominal donor site. She is … Read more

CPT code 32555 coded sample report

Ultrasound guided right thoracentesis Indication: Pleural effusion Findings: Written informed consent was obtained from the patient after  explanation of risks, benefits and alternatives. Limited ultrasound scanning over the back for localization of the right pleural effusion. Overlying skin posteriorly was marked with ultrasound and then sterilely prepped and draped. Local anesthesia with 1% lidocaine. A … Read more

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