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

Same day/same service?

Hey there folks. Looking for some guidance.

Got an e-mail from a provider nurse this morning asking:

"Can you perform (and be paid) for balance testing the same day a patient is discharged from the hospital? I know we cannot get reimbursed for outpatient procedures/exams performed while they are inpatient?"

Thoughts?

Medical Billing and Coding Forum

Admit Discharge same day

We are a teaching hospital and we often have hospital medicine residents that will see/admit a patient at night and then attending will see them the next morning. We want to make sure we are billing correctly for this.

Scenario:
Patient admitted to inpatient by resident at 10:00pm on 4/1/2019.
Attending sees patient at 8:00am on 4/2/2019. Attending makes their note, attests to resident note and decides to discharge the patient. There is an H&P and a Discharge summary.

What should be billed?

Also, same scenario, but admitted to Observation.
What should be billed?

Thank you.

Medical Billing and Coding Forum

Excision of multiple soft tissue masses on same finger

Can you bill for excision of multiple soft tissue masses on the same finger that are done through one incision? In the example below, our doctor doesn’t indicate where on the finger the masses were excised from so I will have to query him. However, I’m wondering even if he does indicate where the STMs were excised from, can we bill for both masses or just one since they were removed through the same incision? Also, any supporting documentation or articles would be helpful! Thanks!

"A dorsal curviliner incision was made on the dorsum of the long finger centering over the soft tissue masses. The incision was carried thru the skin and subcutaneous tissue. Hemostasis was achieved with bipolar electrocautery. The skin was gently elevated off the underlying soft tissue mass with a #15 blade knife. The masses were dissected from the surrounding soft tissue with care taken to protect the neurovascular structures and the extensor tendon. Both masses were excised and sent for microscopic pathology. The extensor tendon remains intact."

Medical Billing and Coding Forum

Observation same day admit/discharge but two different providers from same group

Just want to make sure I’m understanding the guideline correctly..

Patient is admitted and discharge on same day by two different providers who belong to the same group practice …

Provider who admitted patient to observation is the one who gets billed with 99234-36 .. ??

Is that correct?

Help please! :confused:

Medical Billing and Coding Forum

Preventive and Sick same day

Hello,

Wondering if we could get some guidance on billing Preventive and sick visits same day? CPT states that if an abnormality or a pre-exsisting problem is addressed and the problem is significant enough to require additional work, we are able to bill the E/M with a 25 modifier. If the patient comes in with 3 chronic problems, we know that just refilling prescriptions does not qualify but we were wondering if ordering labs to monitor chronics would? Ex: hyperlipidemia is stable on the medication but ordered a lipid panel for next year.

Thanks
Steph

Medical Billing and Coding Forum

Preventive and sick same day

Hello,

Wondering if we could get some guidance on billing Preventive and sick visits same day? CPT states that if an abnormality or a pre-exsisting problem is addressed and the problem is significant enough to require additional work, we are able to bill the E/M with a 25 modifier. If the patient comes in with 3 chronic problems, we know that just refilling prescriptions does not qualify but we were wondering if ordering labs to monitor chronics would? Ex: hyperlipidemia is stable on the medication but ordered a lipid panel for next year.

Thanks
Steph

Medical Billing and Coding Forum