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Tag Archives: Dilated

Dilated cardiomyopathy secondary to Rheumatoid Arthritis

Posted on by
Hello,

Looking for some feedback as what to code for provider stating:

Dilated cardiomyopathy secondary to Rheumatoid Arthritis:

Should it be I42.0 (dialated cardiomyopathy) + M06.9 (Rheumatoid arthritis, unsp)

or

M05.30 (Rheumatoid Arthritis with heart disease, unsp

Any help appreciated!!

Donna

Medical Billing and Coding Forum

2021F Dilated Macular or Fundus Exam Performed, Including Documentation or G8397?

Posted on by
Greetings. Large Ophthalmology Group. Patient was seen a week before for New Patient Routine eye exam without dilation (cpt code 92002)- Patient is on High-Risk medication for HTN, Thyroid dysfunction, and is BORDERLINE diabetic. Patient seen again yesterday for JUST the Dilated macular or fundus exam performed, with all documentation salient to fundus findings. I see that the provider reported 2021F. Wouldn’t the better option have been to either 1) Bill G8397 or 2) Inform the patient that they ".. have medical conditions that warranted further evaluation with a Dilated Medical Exam, so we will just skipt the DFE Screening (that is already included in the patient’s insurance) and instead do the more thorough retinal Medical exam that is billed through your Medical Insurance." ? This could have then been billed with a CPT Code of 992**. Your input is strongly encouraged. I look forward to your replies. 😀

Medical Billing and Coding Forum

Dilated pore of Winer removal

Posted on by
One of my providers removed a dilated pore of Winer, and I am struggling to decide on the appropriate codes to use. (I work in primary care, so derm is not my strong point!)
First, can anyone confirm the ICD-10 I should be using? I don’t know if it should be a follicular disorder or some sort of acne.
Diagnosis aside, I’m more concerned in coming up with the appropriate CPT code(s) for the removal. The procedure note is below. I am partly thrown because here she refers to it as a "cyst," but throughout the rest of the note it is referred to as a lesion, and specified as a pore of Winer. (It’s entirely possible she just selected the incorrect EHR template and "cyst" was entered automatically") The closure is also throwing me. Should this be a 10040 and simple closure code? Or a benign lesion excision and removal?

"Cyst Removal:
The patient complains of changing lesion.
Indication: inflamed lesion

Procedure #1: incision of skin and removal of cyst
Size (in cm): 0.4
Comment: dilated pore of Winer
Instrument used: #11 blade
Anesthesia: 1% lidocaine w/epinephrine
Superficial Suture: 5-0 Nylon
# of superficial sutures: 1

Cleaned and prepped with: betadine
Wound dressing: bacitracin
Instructions: RTC in 5 days"

I’m leaning toward the lesion excision, but like I said, derm is not my strong point. Any guidance toward the right answer here would be very much appreciated! Thank you!

Medical Billing and Coding Forum