Dears,
I want to know if there are ICD10 codes that only acceptable as Principal diagnosis, if yes please send me the ranges and the guidelines.
Thank you
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Tag Archives: only
Lap occlusion of Fallopian tubes, right side only
Hello, new to ob/gyn coding and this has me stumped. CPT 58671 is a bilateral code. If only the right fallopian tube is occluded via band is it coded as 58671-RT. Does it matter if the payor is Medicare or Commerical? Coding for a facility and not a physicians office. Thank you.
Gen Change Only?
Would you code this just 33228, 99152? Would I code for the pocket revision? Thoughts? Thank you!
PROCEDURE PERFORMED:
Medtronic pacemaker generator change.
INDICATIONS:
Pacemaker generator at ERI.
The risks and benefits of pacemaker generator change was discussed with
the patient and her daughter. She is agreeable to the procedure. Consent
was obtained.
Time-out was performed. The patient, procedure, and physician were identified.
She received Versed 1 mg, fentanyl 50 mcg intermittently during the procedure
for conscious sedation.
The patient was prepped and draped in the normal fashion. 1% lidocaine
was infiltrated at the left lateral border of the old pacemaker generator.
A 3 to 4 cm linear incision was made. The patient’s skin was very
thin and the pacemaker generator was notably superficial. The pacemaker
leads were also notably visible under the very thin skin. Bovie cauterization
and blunt dissection were carried down to the pacer capsule. The pacer
capsule was notably heavily calcified with an eggshell case. The pacemaker
generator was externalized and a new pacer was attached to the atrial
and ventricular lead. Note, the atrial lead is a nonfunctional lead.
Rather than leaving a blunt and pacer lead that was capped under a
thin skin, it was decided to place the cap in a dual-chamber head in
an effort to reduce risk for site erosion from the lead tip. The heavily
encasement calcification was meticulously removed. Extensive dissection
and debridement of the calcific shell was performed. The atrial and
ventricular lead were mobilized. The leads were tacked down to reduce
the tension that was previously noted before the procedure in an effort
to reduce risk for lead erosion. The new pacer pocket was made a bit
more inferior than the previous pocket. The pacer was secured to the
pectoralis. The pacemaker pocket was generously irrigated with antibiotic
solution. The pacer pocket was closed with 2-0 Vicryl interrupted sutures
for the deep layers. Generous puckering of the skin was noted to reduce
the tension of the very thin superficial placement of the generator.
The subcuticular layer was closed with 4-0 Monocryl. The incision
was covered with benzoin and Steri-Strips.
The patient awoke from conscious sedation without apparent neurologic
deficit. She was transferred to the holding area in stable condition.
The pacemaker generator is a Medtronic Azure XT DR MRI, model #W1DR01,
serial #.
The atrial lead is model #4271 Boston Scientific, serial #, implanted
10/04/1993.
The right ventricular lead is a Boston Scientific model #4262, serial
#, again serial #. R-wave is 9.9, pacing impedance is
380 ohms, pacing threshold is 1.5 at 0.4 milliseconds. The atrial lead
is inactivated. The impedance was noted to be 114 ohms.
25 Modifier ONLY to be appended by certified coder?
Hello! I am a CPC for the department OBGYN for a large medical group. just spoke with a member of management from the central billing office at my place of work, and they requested that I advise our billers that they may not append the modifier 25 to any office visit if they are not coders. I have never heard tell of this in the many years I have done billing and coding. Does anyone know if this is true? If so, is there a citation where I could see this guideline? I have scoured the web. I can’t find a single thing outside of articles that give scenarios of appropriate usage, and I really need to know if we’ve just been doing it wrong this whole time! Thank you so much in advance!
help on ICD-10 only, plese
Pre-op Diagnosis: dysmenorrhea, uterine fibroids
Post-op Diagnosis: Same
Procedure: Laparoscopic Assisted Vaginal Hysterectomy with right salpingoopherectomy
Post-op Diagnosis: Same
Procedure: Laparoscopic Assisted Vaginal Hysterectomy with right salpingoopherectomy
Findings: Enlarged bulky fibroid uterus with adhesion of omentum to left cornua. Uterus weight 220 grams.
and this one ICD 10 only
Preoperative diagnosis: Abdominal pain in the setting of prior cholecystectomy
Findings: The esophagus was successfully intubated under direct vision without detailed examination of the pharynx, larynx, and associated structures, and upper GI tract. One stent originating in the biliary tree was emerging from the major papilla. A biliary sphincterotomy had been performed. The sphincterotomy appeared open. One stent was removed from the biliary tree using a snare. A short 0.035 inch Soft Jagwire was passed into the biliary tree. The 12 mm to 15 mm balloon was passed over the guidewire and the bile duct was then deeply cannulated. Contrast was injected. I personally interpreted the bile duct images. There was brisk flow of contrast through the ducts. Image quality was excellent. Contrast extended to the hepatic ducts. A cholecystectomy had been performed. The main bile duct was mildly dilated and diffusely dilated. The largest diameter was 11mm. The lower third of the main bile duct contained one mobile filling defect thought to be a stone, which was small. The biliary tree was swept with a 12 mm balloon and 15 mm balloon starting at the lower third of the main duct and bifurcation. A small amount of biliary debris was swept from the duct. Nothing remained on final occlusion cholangiogram and balloon sweep.
Findings: The esophagus was successfully intubated under direct vision without detailed examination of the pharynx, larynx, and associated structures, and upper GI tract. One stent originating in the biliary tree was emerging from the major papilla. A biliary sphincterotomy had been performed. The sphincterotomy appeared open. One stent was removed from the biliary tree using a snare. A short 0.035 inch Soft Jagwire was passed into the biliary tree. The 12 mm to 15 mm balloon was passed over the guidewire and the bile duct was then deeply cannulated. Contrast was injected. I personally interpreted the bile duct images. There was brisk flow of contrast through the ducts. Image quality was excellent. Contrast extended to the hepatic ducts. A cholecystectomy had been performed. The main bile duct was mildly dilated and diffusely dilated. The largest diameter was 11mm. The lower third of the main bile duct contained one mobile filling defect thought to be a stone, which was small. The biliary tree was swept with a 12 mm balloon and 15 mm balloon starting at the lower third of the main duct and bifurcation. A small amount of biliary debris was swept from the duct. Nothing remained on final occlusion cholangiogram and balloon sweep.
Estimated Blood Loss: Estimated blood loss: none.
Impression: – One stent from the biliary tree was seen in the major papilla and was removed.
– Prior biliary endoscopic sphincterotomy appeared open.
– The entire main bile duct was mildly dilated.
– Choledocholithiasis was found. Complete removal was accomplished by balloon extraction.
Diagnosis:
Calculus of bile duct without cholecystitis or obstruction
Can you bill for UA done in office with only documentation being the results?
A patient came in to PCP’s office to do a urine sample- the MA did a urine dip. They billed for 81002 but I do not have documentation by a nurse or doc indicating the patient was here…. I know the patient was because the results are in chart. My question is are the urine results proper documentation to support billing 81002? At my previous practice the MA always did a note with why patient coming in for urine sample and what physician was in the office…etc. and included the results. Newer to auditing and needing some advice. Thank you!
In Office Lab Draw Only
If we draw labs in our office (CLIA waiver in place) and send them out to a lab for results is the correct cpt code for the lab draw 36415? If so, has anyone had billing issues?
Thank you
Billing E/M code for new pt STD screening only
Our provider sometimes sees new patients at our walk-in clinic who only want STD screening and have no symptoms. An ROS and brief exam are always done. Can I bill an E/M code for these cases or just the lab draw?
Stillborn delivery of placenta only
I need help with a 20 weeks delivery, patient had delivered fetus prior to dr entering the room. Dr only delivered the placenta. I am questioning myself as to whether it should be 59414.