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CPT code 10080 versus 10081
I am trying to code an I&D of a pilonidal cyst. CPT 10080 is simple and 10081 is complicated. How to do I know which code to choose?
Question:
I am trying to code an I&D of a pilonidal cyst. CPT 10080 is simple and 10081 is complicated. How to do I know which code to choose?
Answer:
Great question, you would report CPT 10081 (complicated) if the procedure requires marsupialization, approximation of the wound’s edges, and/or primary closure.
*This response is based on the best information available as of 06/02/22.
Acute Versus Chronic Conditions for Office E/M Services
When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on if the condition is considered a chronic or acute condition?
Question:
When determining if an illness is chronic versus acute is it based on how long the patient has had the condition or is it based on if the condition is considered a chronic or acute condition?
Answer:
The AMA defines chronic as: A problem with an expected duration of at least a year or until the death of the patient.
An Acute problem is “A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected..” An acute problem can be uncomplicated, acute complicated or acute with systemic symptoms. Please reference this link for the AMA definitions.https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.
Keep in mind the practitioner should document the whether the condition is acute or chronic if the condition is stable or exacerbating.
*This response is based on the best information available as of 05/05/22.
New Patient Visit Denied, What Should I Do?
One of our dermatologists saw a patient the first time in our office. We billed 99204. The insurance carried denied the service. I contacted the insurance carrier and was told that the patient was an established patient to the practice and should be reported as an established patient. The patient did see another dermatologist in our group practice who did an intralesional injection a year ago, but it was in another city. Is the insurance carrier correct or should I appeal this?
Question:
One of our dermatologists saw a patient the first time in our office. We billed 99204. The insurance carried denied the service. I contacted the insurance carrier and was told that the patient was an established patient to the practice and should be reported as an established patient. The patient did see another dermatologist in our group practice who did an intralesional injection a year ago, but it was in another city. Is the insurance carrier correct or should I appeal this?
Answer:
Since the dermatologist in the other city is part of your group and is of the same specialty with the same taxonomy code, the patient encounter for the physician in your office should be coded as an established patient visit not a new patient visit.
Per CPT Coding Guidelines: “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of theexactsame specialty andsubspecialtywho belongs to the same group practice, within the past three years.”
Since your claims was denied, it is recommended that you file a corrected claim and bill the encounter as an established patient.
*This response is based on the best information available as of 04/7/22.
Counting Problems Addressed for Medical Decision Making
If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?
Question:
If a patient has one stable chronic illness and one acute uncomplicated illness without systemic symptoms, can we “up” the level of Problems Addressed to Moderate?
Answer:
No, sorry, unfortunately it does not work that way. The problems are no additive or cumulative. One stable chronic illness and one acute uncomplicated illness without systemic symptoms is still Low Problems Addressed.
*This response is based on the best information available as of 03/24/22.
Waiving Medicare Cost-share for Telehealth Visits
I heard that Medicare patients don’t have to pay their deductible or coinsurance if they have a telemedicine visit. Is this true?
Question:
I heard that Medicare patients don’t have to pay their deductible or coinsurance if they have a telemedicine visit. Is this true?
Answer:
Medicare is not waiving deductibles or co-insurance. However, they are allowing providers to do so at their discretion without penalty for telemedicine visits. This means the provider will only be reimbursed what Medicare pays, if the provider chooses to waive the patient portion of the visit. Many payors are waiving cost-sharing for telemedicine visits. See Payor Telehealth Policies for more information.
*This response is based on the best information available as of 03/10/22.
2021 E/M Guidelines MDM Table
We are using the 2021 E/M guidelines in the office and in most cases base the level of service on medical decision making. If I have a patient with a chronic condition that is stable who also has diabetes in which the Internist (nor our specialty) is managing, can I assume the number and complexity of problems addressed is moderate since I have 2 diagnoses?
Question:
We are using the 2021 E/M guidelines in the office and in most cases base the level of service on medical decision making. If I have a patient with a chronic condition that is stable who also has diabetes in which the Internist (nor our specialty) is managing, can I assume the number and complexity of problems addressed is moderate since I have 2 diagnoses?
Answer:
If the physician is not managing the diabetes, it cannot be counted toward complexity of problems addressed. In this situation since the chronic condition is stable it equated to low for the element. Keep in mind you also have two other elements for medical decision making; amount of and/or complexity of data to be review and risk of complications and/or morbidity of patient management. Two of three elements must be met to support the level of medical decision making.
*This response is based on the best information available as of 02/24/22.