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Click here for more sample CPC practice exam questions and answers with full rationale

Coding resolved conditions ALONG WITH current conditions

I know that follow-up visits for resolved conditions are to be coded with the follow-up code (typically Z09) and then the history code for the now-resolved condition.

My question is:

How do you code / sequence codes for a visit that includes BOTH resolved AND ongoing and/or chronic conditions?

Here are a few examples of what I mean, where I am unsure of how you would code / sequence these…


  1. Patient is seen for:
    B/l foot pain due to an injury
    Sleep disorder due to shift work

    The sleep disorder has resolved because the patient switched their shift at work, but the foot pain continues as the injury is still healing.

    ——————————

  2. Patient is seen for:
    URI

    All URI symptoms have resolved. Patient mentions dysuria and is given antibiotics for UTI.

    —————

  3. Patient is seen for:
    Final wound check from laceration
    Hypertension (already diagnosed – chronic)

    Wound is completely healed. Hypertension is stable.

I am not having any luck finding guidance on this, so I really appreciate any help you can give!! Thank you!!

Medical Billing and Coding Forum

CT with IV Contrast along with hydration

I need some help please. So a CT of the chest with IV contrast was done. Then after that, hydration was given for 45 minutes. My understanding is that you would not bill for the administration of the IV contrast as it is included with the CT. So my dilemma is coding for the administration of the hydration. Would I use the initial code 96360 or the secondary code 96361? I have tried it both ways and have gotten denials from BCBS for both ways. I have tried 96360-59 and I have tried 96361-59 and I have also tried 96361 without a modifier. Nothing seems to work. Can anyone tell me what I am doing wrong?

Medical Billing and Coding Forum

Revision of Uterus along with Recanalization of Cervix with Cervical Stent Placement

Does anyone know the correct CPT code to use for the following procedure?

PROCEDURE IN DETAIL: Patient was taken to the operating room and was placed in dorsal lithotomy position and was prepped and draped in standard surgical fashion.
*
Intra-abdominal entry was not made in this patient. The patient was examined under anesthesia. It appeared that patient had a rather aggressive LEEP in the past. Her cervix was virtually absent. When we placed the duck billed speculum in the vagina we could not find a cervix or a cervical opening.
*
Intraoperative ultrasound was then performed which demonstrated a large collection of blood within the uterus with complete occlusion of the presumed cervical endocervical canal.
*
Patient wanted to have kids and therefore a recanalization procedure along with division of the uterus was needed.
*
Subsequently, multiple lacrimal duct probes were taken and a tentative cervical canal was formed with lacrimal duct probe and under ultrasound guidance an opening into the uterus was made in a transvaginal fashion. As soon as we entered the uterus, old hematometra was evacuated, evacuating approximately 200 mL of blood under ultrasound guidance. This blood was old and altered. Subsequently, we needed to suture the upper vagina to the endocervical canal with multiple interrupted stitches and the minimal cervical tissue that was found was subsequently sutured onto itself with a cervical stent. A red rubber Foley catheter was subsequently inserted into the uterus and was passed through the vagina to keep the newly created endocervical canal open.
*
The red rubber Foley catheter was basted to the right thigh of a patient. Multiple intraoperative pictures with ultrasound guidance were taken and were uploaded to the patient’s chart.

I have NO idea. My surgeon wants me to use 58540 but that does not seem correct to me.

Any help is greatly appreciated!! 😮

Medical Billing and Coding Forum

CPT 52356 along with dilation for ureteral stenosis

I’m finding some conflicting information for this procedure whether the dilation would be separately billable.

Procedure: Urethral dilation, cystoscopy, right retrograde pyelogram, right ureteral dilation, right rigid ureteroscopy, right flexible digital ureteral pyeloscopy, laser lithotripsy of ureteral and renal calculi, placement of right double-J stent 6 x 26.

A 22-French cystoscope was then used to evaluate the patient. The patient was noted to have meatal stenosis. He underwent dilation of the fossa navicularis with Van Buren sounds up to 24-French.
*
A 22-French cystoscope was then used to evaluate the patient. The anterior urethra was normal in appearance without any evidence of stricture. His urethrovesical anastomosis was intact. Upon entering the bladder, both ureteral orifices were identified, appeared to be in orthotopic position with clear
efflux of urine. Systematic evaluation of the bladder with a 30- and 70-degree angle lens demonstrated no gross intravesical pathology. Specifically, no gross inflammation, tumor, or calculi.
*
A right retrograde pyelogram was performed. This demonstrated what appeared to be a stone near the iliac vessels. There was also evidence of calcification in the lower pole of the right kidney. The ureteral orifice was dilated with a Nottingham dilator. The cystoscope was then withdrawn.
*
A 6.9-French semi-rigid ureteroscope was then used to evaluate the patient. The distal ureter was normal in appearance up to the iliac vessels. The stone appeared to be proximal to the iliac vessels, but unfortunately, I was unable to navigate the semi-rigid ureteroscope proximal to the iliac vessels. At this point, an additional wire was then placed through the working port of the semi-rigid ureteroscope and the ureteroscope was withdrawn.
*
The digital ureteroscope was then advanced over the wire. We were able to identify the stone just proximal to the iliac vessels. Using the holmium laser, the stone was then dusted into multiple small fragments. The ureteroscope was then advanced at this point and a wire was placed through the digital ureteroscope and the ureteroscope was withdrawn. An 11 x 13 x 44 ureteral access sheath was then advanced. I was unable to advance the
ureteral access sheath proximal to the iliac vessels. Given this finding, I did place an additional wire, then advanced the ureteral scope into the right renal pelvis. The patient’s major stone burden was in the lower pole of the right kidney. The stone was then broken up into multiple small fragments. These fragments were too small to engage in a Nitinol basket. Systematic evaluation on remainder of the calyces demonstrated no evidence of any significant residual stone burden. At this point, then a retrograde pyelogram was performed through the scope. There did not appear to be any evidence of extravasation nor residual stone burden. The ureter was then examined as the ureteral scope was withdrawn. A 6 x 26 double-J stent was then placed into the right renal pelvis in a retrograde fashion under fluoroscopic guidance. The bladder was drained. The cystoscope was withdrawn. Please note, there was 1 stone fragment, which was retained, which will be sent for analysis. The patient tolerated the procedure well and was taken to the recovery room postoperatively. We will arrange for patient be discharged home with prescriptions for ciprofloxacin, Norco, and Ditropan. Mid-
level follow up in 1 week with KUB.

Medical Billing and Coding Forum

Billing E/M codes along with a therapeutic procedure or a diagnostic procedure

We are struggling with when or if it is ok to bill an E/M office visits with a therapeutic procedure or a diagnostic procedure. How do you know what is considered therapeutic and what is diagnostic? We were told it is up to the discretion of the physician. If a provider only pays for either the E/M or the procedure, can I use modifier 25 to get both paid?

Thank you!

Medical Billing and Coding Forum

Resection of large intra-abdominal cyst along with left neprectomy

I am having trouble finding the correct cpt codes to use for the following surgery:

Operation: Exploratory laparotomy, resection of large left-sided intra-abdominal cyst along with left nephrectomy, closure of enterotomy.

Description of Operative Procedure:
With the patient on the operation room table in the supine position, a 16 French Foley catheter was place for 200 ml amber urine; then, the abdomen was shaved, prepped and draped in the usual sterile fashion. A xiphoid to pubis mid-line abdominal incision was made and carried through into the peritoneum. Retractors were placed, and the cyst was gradually freed from the surrounding tissue with a combination of blunt and sharp dissection. The gonadal vessels were doubly ligated between 0 silk ties and divided in order to free up the medial aspect of the cyst. The transverse mesocolon was incised with the harmonic scalpel in order to expose the left renal fossa. It became obvious that the cyst was intimately associated with the left kidney, and as the latter appeared to be end-stage, we elected to remove the kidney en block with the specimen. Accordingly, the left renal vein was doubly ligated with 0 silk ties and suture-ligated with a 2-0 silk tie prior to dividing. The left renal artery was double=y tied with 0 sild ties and divided, and then the harmonic scalpel was used to divided the remaining attachments; the specimen was then removed.

A 2 cm tear was noted along the antimesenteric border of the distal transverse colon. A small serosal avulsion was repaired by including this in the enterotomy closure with the TA-55 stapler, and then the enterotomy site was imbricated with interrupted 2-0 silk lambert sutures. The abdomen was closed with interrupted 0 vicryl suture and the skin was loosely closed with the stapler.

Any ideas?

Medical Billing and Coding Forum

HELP!!! Billing for cosmetic along with medically payable skin tags

Has anyone come across their physician removing skin tags that are inflamed, bleeding and changing in appearance along with ones that are considered cosmetic? If so how did you bill to accommodate both? I am pretty new to derm billing and have never come across a situation that both types were removed. I don’t feel confident in billing both the patient for the cosmetic ones and procedure code 11200. If any one has any experience in this, I would greatly appreciate direction.

Medical Billing and Coding Forum