General Question for the Week of March 15, 2021
Is there somewhere a list of typical “minor” procedures is documented? And am I correct that Medicare states the attending physician must be present for the entire procedure for minor procedures?
Is there somewhere a list of typical “minor” procedures is documented? And am I correct that Medicare states the attending physician must be present for the entire procedure for minor procedures?
For ultrasound exams that are non-diagnostic due to gas, body habitus, etc. is it appropriate to down code to a limited exam (if ordered as complete) and append a modifier 52?
Can you explain the differences between PTP, MUE, and AOC edits mentioned in last week’s question?
Can you tell me more about the background basics of NCCI edits?
We have a question regarding the requirement, if any, for the technique in an MRI report. Sometimes we don’t get any technique, but here are some examples of what we are getting: “TECHNIQUE: MRI of the right knee was performed before and after the uneventful intravenous administration of 12/17 mL ProHance.” “TECHNIQUE: MR images were obtained of the left hip without intravenous or intra-articular contrast.” Should we be insisting on a description of the images that were obtained?
What is the difference between oral hydration and intravenous hydration therapy?
What are the documentation requirements to bill for hydration?
I am trying to find a diagnosis code for chronic anterior cruciate ligament tear of the right knee. The clinical history is knee pain, evaluate meniscus and cartilage with history of recurrent patella subluxation. If I go to tear ligament it directs you to sprain. Sprain cruciate ligament, anterior is S83.511, which doesn’t seem right because this isn’t a current tear. Any suggestions?
What is the appropriate ICD-10-CM for retrolisthesis of C5 relative to C6? There is nothing in ICD-10 under “retrolisthesis” and I wasn’t sure if you go to “displacement” intervertebral disc, cervical M50.222? Or is there another term to look under for retrolisthesis. Does the doctor need to change how he documents this problem?
I am trying to find a diagnosis code for chronic anterior cruciate ligament tear of the right knee. The clinical history is knee pain, evaluate meniscus and cartilage with history of recurrent patella subluxation. If I go to tear ligament it directs you to sprain. Sprain cruciate ligament, anterior is S83.511, which doesn’t seem right because this isn’t a current tear. Any suggestions?
One of our breast-center doctors does not specify tomosynthesis in the technique section of mammograms, but tomosynthesis views are mentioned in the body of the report. Does she have to dictate them in the technique or will it be enough that it is mentioned in the body?
Can we bill for an ultrasound done with a handheld device? Are there special guidelines for this? I know that Clinical Examples in Radiology (CER) noted in 2012 that a hand-held device could not be used for 76937.
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