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12/23/2009    

CODINGLINE CORNER

Query: Hallux Valgus Repair


We are trying to the locate the appropriate code(s) for a hallux varus repair by capsulotomy and Mini-TightRope.


Joy Constanzo, Billing Supervisor, Office of Kirk Koepsel, DPM,

Houston, TX


Response: There is no specific code for this service. You should bill for the actual procedure(s) performed. It this case, your options could include CPT 28270 which is capsulotomy metatarsal-phalangeal joint, or CPT 28313 (reconstruction angular deformity of toes, soft tissue procedure only).


There is no code for the TightRope use. It is a product used in the primary repair procedure. If you feel the work done was significant enough, append a "-22" modifier. The op report should clearly document that work. Be sure to include a letter of explanation.


Tony Poggio, DPM, Alameda, CA


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Other messages in this thread:


01/20/2017    

CODINGLINE CORNER


Query: Nerve Biopsies


 


Can anyone please tell me what diagnosis you are using for Medicare patients who have a nerve biopsy done?


 


Danielle LaLonde, Belvidere, NJ


 


Response: We have used peripheral neuropathy as the diagnosis in the past. Of course, with ICD-9, we could use ICD-9 356.9, but that crosswalks to G60.9 which is an unspecified code in ICD-10. I would look at the range G57-G60 and pick the most appropriate code that describes the patient’s condition.


 


You could also check in the APMA Coding Resource Center by entering the CPT code, and looking to see what is offered under CPT to ICD-10 suggested links. There will be suggestions for diagnosis coding for most procedure CPT codes. Unfortunately, if you are using CPT 94795 for your biopsy of nerve code, there are no suggested diagnosis codes.


 


Katherine Sharp, Woodbury, TN


 


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01/18/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Tom Silver, DPM


 


We finally addressed this problem of unmet deductibles last January when we started asking patients for their credit card, to keep it "temporarily" on file.  Our policy states that once we know what their insurance allows, we will notify the patient of their balance by phone as to the amount we will be applying to their credit card (unless they want to make other arrangements).  


 


Since some patients refuse to give us their credit card, I need to decide if we should start asking for a percent of their charges at the time of service, since they will have to pay a certain amount out of pocket anyways when their deductible isn't met.


 


Tom Silver, DPM, Minneapolis, MN

01/17/2017    

CODINGLINE CORNER


Query: PQRS for 2017


 


Has PQRS been completely eliminated for 2017 in lieu of CMS’s implementation of the Quality Payment Program and MIPS? For 2017, do we need to still track the PQRS measures using the “G” codes and other codes established for PQRS in the past?


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: PQRS no longer exists in 2017. MACRA began January 1, 2017. PQRS and Meaningful Use are over. One way to participate in MACRA is through the Merit-Based Incentive Payment System (MIPS).


 


One of the three reporting categories of MIPS in 2017 is “Quality”. Full MIPS participation requires reporting on 6 quality measures. These quality measures are very similar or identical to the PQRS measures that you are referring to, some of which are reported using “G” codes.


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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01/16/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Charles Morelli, DPM


 


My opinion on this practice is a simple one. CHARGE YOUR PATIENTS FOR THEIR DEDUCTIBLES. Most of use have EMR software that connects directly with Medicare and many commercial carriers, and lets you know exactly what a patient's deductible is. You can tell your patient this information prior to their appointment, assuming you call patients to remind them of their appointments, or they can be told when they arrive and let them know that their deductible needs to be paid BEFORE they are seen (as well as their co-pays).


 


When we see patients in November/December and they make a follow-up appointment for the new year, we tell them at that time that they will be paying for their next visit (assuming that the deductible has not been met previously or they do not have a secondary carrier that picks up that amount). Stop working for free and stop being afraid to ask (or tell) your patients that they need to pay for their treatments. 


 


Charles Morelli, DPM, Mamaroneck, NY

01/13/2017    

CODINGLINE CORNER


Query: Holding Billing at the Beginning of the Year


 


I have read in the past, opinions on the pros and cons of holding your billing for the first 1-2 months of a new year to avoid hitting everyone’s deductible. Do readers on this forum have an opinion on this practice?


 


Jennifer, Office of Charles Perry, DPM, Cambridge, OH


 


Response: You should check with your payers because I have found that this actually may be against your contract in many cases.


 


Anna Sanders, Clarksville, TN


 


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01/10/2017    

CODINGLINE CORNER


Query: Bunionectomy with Implant Coding


 


Now that CPT has revised the bunionectomy codes for 2017, deleting CPT 28293 (correction, hallux valgus [bunion], with or without sesamoidectomy; resection of joint with implant), what is the new code for insertion of a total 1st metatarsal-phalangeal joint implant?


 


Mike King, DPM, Alpharetta, GA


 


Response: If the 1st metatarsal-phalangeal joint implant is inserted as part of a hallux rigidus repair, the appropriate code for 2017 is CPT 28291 (hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant).


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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01/09/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Jerry Peterson, DPM


 


Before you go calling the State Board, I suggest that you contact your state association’s representative on legislative activities. I am sure they have a committee and chairperson on this. If not, ask the component president. Going to the state could cause the opening of a can of worms when you don’t ask the right people the correct question.


 


When you deal with government or any regulatory agency, you always want to know the answer BEFORE you ask the question! There may be better people to ask.


 


Jerry Peterson, DPM, West Linn, OR

01/06/2017    

CODINGLINE CORNER


Query: Staff Performing CPT 17110


 


Can the office staff perform CPT 17110 (destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) and bill this code without the doctor being in the office?


 


Anna Sanders, Clarksville, TN


 


Response: In my opinion, the answer would be a resounding “no.” In the State of Illinois, if an unlicensed staff member provides procedural or surgical treatment as described in the post, it would be practicing medicine without a license. Not only would it be illegal to perform said treatment, but also to bill an insurance carrier for the surgical services performed by an unlicensed member of the doctor’s staff.


 


I recommend you check with your state licensing board (my response may not be the same for your state). If you do check with your licensing board and get a response, I would appreciate you sharing it with us.


 


Joseph Borreggine, DPM, Charleston, IL


 


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01/03/2017    

CODINGLINE CORNER


Query: Covering a Colleague's Office


 


I have a colleague who is recovering from surgery and needs help covering in his office. I would like to help, volunteering my time on a limited basis. Would there be any ramifications if I went to his office to treat his patients and just allow the office to bill under his Medicare number? I am not asking for any remuneration. I’m asking this question more regarding the legality as well as any malpractice coverage or Medicare liabilities.


 


Codingline Archive Question


 


Response: His staff billing for the services will bill those services just as if your colleague had provided the service. They will add a “Q6” modifier to the claim codes so that Medicare would know a locums (that’s you) was providing this on a temporary basis (no more than 60 days).


 


This happens a lot and that is very generous and commendable of you to help your colleague like that.


 


Don Self, Whitehouse, TX


 


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12/30/2016    

CODINGLINE CORNER


Query: Must Sensation be Absent to Bill *Q9*?


 


I would like to bill Medicare for CPT 11721 on a patient with type 2 diabetes, who has one absent pedal pulse and has completely intact light touch sensation in her feet. She, however, reports burning and tingling of her feet. As long as I document a primary care provider visit within the past 6 months, will this be covered using a "Q9" modifier? 


 


Troy Harris, DPM, Swansboro, NC 


 


Response: The "Q9" modifier represents the presumption of coverage when the physician rendering the routine foot care has identified one class B and two class C findings. 


 


You note that the patient has one absent pulse (either dorsalis pedis or posterior tibial), so the single class B finding is met. 


 


The class C findings options are: Claudication; Temperature changes (e.g., cold feet); Edema; Paresthesias; and Burning. 


 


The tingling sensations described by the patient would qualify for paresthesia. So, the patient describes (and you documented) both paresthesias and burning in the feet - two class C findings. The presumption of coverage ("Q9") appears to have been met. By the way, you still would need to document "the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement" as well as qualifying diagnoses for your records and claims. 


 


Tony Poggio, DPM, Alameda, CA 


 


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12/29/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A



From: Harry Goldsmith, DPM


 


I disagree with Dr. Landsman. If you are performing a destruction of neuroma (I am presuming it is an interdigital [Morton's-type neuroma]), you would look to the nerve destruction codes. In this case, CPT 64632 is described as "destruction by neurolytic agent; plantar common digital nerve." CPT 64632 falls under the heading "Destruction by Neurolytic Agent (e.g., Chemical, Thermal, Electrical or Radiofrequency)."


 


The original post in Codingline noted the author was using the Neurotherm unit for radiofrequency destruction. However, the Neurotherm website/page notes that the unit is a radiofrequency generator, delivering "pulsed or pulsed dosed treatments to painful nerve sites to help manage chronic pain."


 


CPT instructions for the “destruction by neurolytic agent” section specifically say, "Do not report a code labeled as destruction when using therapies that are not destructive of the target nerve (e.g., pulsed radiofrequency), use CPT 64999." Unless there is something about the Neurotherm machine's radiofrequency delivery beyond what the company included in their website, the proper code to use in this case is CPT 64999 (unlisted procedure, nervous system). 


 


Harry Goldsmith, DPM, Cerritos, CA

12/28/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Adam Landsman, DPM, PhD


 


The proper code treatment of a neuroma using a Neurotherm machine is CPT 64640.


 


Adam Landsman, DPM, PhD, Boston, MA

12/27/2016    

CODINGLINE CORNER


Query: Radiofrequency Coding


 


I have a Medicare (Nassau County, New York) patient with a painful neuroma. How would one bill for radiofrequency destruction using a Neurotherm machine in terms of CPT and diagnostic coding? 


 


David Sands, DPM, Great Neck, NY


 


Response: The Neurotherm machine use involves no specific CPT code use that I am aware of. You are in New York and your NGS is your Medicare contractor. I looked on their website for specific neuroma coding guidance and did not see any.  


 


For destruction, when you think neuroma, you look in the nerve section, for example, CPT 64632 (destruction by neurolytic agent; plantar common digital nerve). This means you are using a neurolytic agent that is destructive. I do not believe the Neurotherm machine meets the description. If it is not destructive but therapeutic, you would use a code like CPT 64999 (unlisted procedure, nervous system). This therapy is probably going to a CASH service. 


 


You did not give the exact anatomical location for the neuroma, so the most common neuroma ICD-10 codes are: 


G57.61 Lesion of plantar nerve, right lower limb 


G57.62 Lesion of plantar nerve, left lower limb 


G57.63 Lesion of plantar nerve, bilateral lower limbs 


 


David J. Freedman, DPM, CPC, Silver Spring, MD 


 


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12/23/2016    

CODINGLINE CORNER


Query: Debridement During a Global Period


 


We have a patient who is in the post-op global period for a toe amputation. At his last visit, he presented a new problem requiring the doctor to perform CPT 11042 (debridement, to and including subcutaneous tissue). Is it correct to bill CPT 11042 with both modifiers "-79" and "-58"? 


 


Vanessa Sloan, Effingham, IL 


 


Response: A toe amputation has a 90-day global so debridement of the amputation site within the global period may be included in the amputation global fee allowance depending on the payer. This is especially true for Medicare if the procedure is not performed in an operating room. 


 


Your chart note must be very clear as to what you mean by "he presented with a new problem." I wasn't clear as to whether the ulcer was at the same or a different site than the amputation. If it was the same site, when the patient stubbed his foot, did the wound open resulting in the need for the debridement or was the amputation site in need of local clean up despite the contusion? 


 


The "-58" modifier implies a staged or related procedure while the "-79" modifier is reserved for a completely unrelated procedure. You cannot apply both to a procedure. 


 


Tony Poggio, DPM, Alameda CA 


 


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12/20/2016    

CODINGLINE CORNER


RE: Bone Graft at Bunionectomy Site


 


Is CPT 20957 (bone graft with microvascular anastomosis; metatarsal) an appropriate code to use when an autologous bone graft for the bunionectomy site was used to rotate the cartilage of the head of the first metatarsal for treatment of hallux limitus/valgus? Can we also bill CPT 28296? 


 


Name Withheld by Moderator


 


Response: Typically, rather than actually performing a microvascular anastomosis, surgeons use an autograph (from the same metatarsal) to address hallux limitus. If that is the case here, in my opinion, it is globally included in CPT 28296. 


 


Rick Horsman, DPM, Olympia, WA 


 


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12/16/2016    

CODINGLINE CORNER


Query: 2017 Medicare Digital X-Ray Requirements


 


If we are taking x-rays digitally as of January 1, 2017, no change is required to our current billing for x-rays. If we are NOT taking x-rays digitally as of January 1, 2017, then we need to add a modifier onto the technical component. Is the modifier actually "XX" or is that just used as a placeholder above? 


 


Michael Nirenberg, DPM, Merrillville, IN


 


Response: Beginning January 1, 2017, CMS will be reducing by 20% of the Medicare fee schedule allowance the TECHNICAL COMPONENT (TC) allowance for any x-rays billed that still use film. From January 1, 2017 on, doctors/practices taking and billing for x-rays that use film will be required to append an "FX" modifier to the global x-ray code to indicate they are still using film. 


 


Beginning 2018, practices using "computed radiology" (CR) where imaging is obtain via a cassette or imaging plate, the final rule "provides a 7% reduction in Medicare x-ray payments. CMS promises more details prior to the 2018 implementation date. So, to answer your question, if you are using a digital x-ray system in 2017 and NOT obtaining your radiologic image on film, you do not have to do anything. You would bill as you previously have. If you are still using film, you add the "FX" modifier to your global x-ray code. For example, CPT 73630-FX-LT. Medicare will "automatically" reduce by 20% the technical component portion allowance for you. 


 


Tony Poggio, DPM, Alameda, CA 


 


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12/13/2016    

CODINGLINE CORNER


Query: PQRS *Diabetic Shoe Size*


 


When we enter our diabetic patients' shoe size (PQRS) in our documentation, must we actually measure the patient's foot or can we just ask and document what they tell us? Also, do we need a width entered? 


 


Jeffrey Klein, DPM, Waterford, MI


 


Response: The actual PQRS measure noted on the CMS PQRS website stipulates that you measure the patient's feet with a standard measuring device. Thus, you cannot simply record the patient's shoe size from the patient (or family), even if you believe that the size shoe they are wearing is appropriate. 


 


You must also record which type of standard device (e.g., Ritz stick or Brannock device) you are using. Because both of these devices are capable of measuring both size and width, to record those numbers as both are important variables in determining whether the patient is wearing an appropriate sized shoe. 


 


Paul Kesselman, DPM, Woodside, NY 


 


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12/09/2016    

CODINGLINE CORNER


Query: Tarsal Tunnel Injection Coding


 


The doctor is injecting a steroid/lidocaine combo to treat the tarsal tunnel complaint. What code would be best to use for this injection? 


 


Katherine Sharp, Woodbury, TN


 


Response: I suggest CPT 64450 (injection, anesthetic agent; other peripheral nerve or branch).  You can also bill for the steroid product. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 


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12/06/2016    

CODINGLINE CORNER


Query: Orthotics and PF Straps


 


We recently received a denial when we billed for foot orthotics and a plantar fasciitis strap on the same day. Can anyone tell me if this is billable? 


 


Danielle LaLonde, Belvidere, NJ


 


Response: Likely not. It seems implausible that you would be strapping the foot and providing the patient with custom foot orthotics on the same day. Grounds for appeal could be that you did not expect the patient to wear the devices all day and that they are to be used on a trial basis for the first two weeks, with increasing use by one hour more per day. Thus, the need for strapping on the same date as the dispensing. Your notes would have to substantiate this. 


 


For most of the notes on foot orthotics I have reviewed, this would not seem to be the overall trend and it would be an exception. Thus, the need to improve one's dispensing notes documentation is apparent. I would also be cautious about this because if the case is rather that you are billing for the foot orthotics prior to dispensing (e.g., date you are casting) and this is not in accordance with the insurance carrier's policy, this would definitely be inappropriate. The payer would not know that you did not dispense the device, and your appeal would indicate that. 


 


Paul Kesselman, DPM, Woodside, NY


 


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12/02/2016    

CODINGLINE CORNER


Query: Hospital Consultation Coding Issue


 


We have a patient whom we did a consult on at the hospital. We billed it as CPT 99223 (initial hospital consult) to the patient's insurance -- in this case, the patient has Bluecare (Tenncare/Medicaid plan). They are denying the claim, stating there's a more "appropriate code" that we need to bill. I pulled records from the hospital and the only thing I can figure is that the hospital had the patient marked as "OBSERVATION" the entire time she was there (08-10-2016 16:31pm to 08-11-2016 21:55pm). So, we think that would mean they want us to bill a CPT 99218-99220 code for "hospital observation". However, we did NOT admit this patient and the way that those codes read, they are only to be billed by the physician who actually admitted the patient. Does anyone have any insight on this? Are we correct on our CPT 99223 coding? Do I need to file an appeal or can we bill the observation code? 


 


Jennifer P. Memphis, TN


 


Response: CPT 99223 is a very high level consultation code. The payer may have an edit in place against podiatrists or other specialists using this code. There are many things required to satisfy a CPT 99223 level E/M service. Among them is that you perform 10 Review of Systems that are appropriate for the problem you are evaluating. These systems include GI, GU, Eyes, ENT, CV, Respiratory, and others. 


 


Also required is a full organ system exam. When you look through all the full organ system exams, most require opthalmoscope, otoscope, and other things most podiatrists aren’t doing as a consultant. Even the musculoskeletal full organ system exam requires skin inspection, muscle strength, and range of motion of both upper extremities. Take a close look at ALL of the requirements of CPT 99221, CPT 99222, and CPT 99223 before choosing your code. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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11/29/2016    

CODINGLINE CORNER


Query: CPT 99212 or 99213?


 


When billing for a chief complaint of bunion, heel pain, or hammertoe, when the evaluation/medical decision-making is straightforward with one chief complaint and the plan only involves educating the patient of the deformity (no prescription given and no therapy/treatment ordered), should this be CPT 99212 or CPT 99213? 


 


Danielle LaLonde, Belvidere, NJ


 


Response: There are office visits where counseling is the primary service performed - patient education about their condition, treatment options, risks, etc. In these cases, use "time" as the basis for selecting your E/M service. In the CPT book, each E/M code for any place of service has time period associated with it. If over 7.5 minutes is spent with a patient in counseling/coordination of care (over 50% of the encounter time was spent in counseling) during a 15 minute face-to-face encounter, then CPT 99213 would be appropriate, as long as your documentation is clear regarding the issue(s) discussed and the medical necessity for the counselling. Both times should be documented within the medical record. 


 


Tony Poggio, DPM, Alameda, CA


 


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11/25/2016    

CODINGLINE CORNER


Query: Coding Laser Treatment of Neuromas


 


I want to offer laser treatment of neuromas. Guidelines for the laser use suggested up to 10 treatments 3 to 4 days apart. How would this best be billed? I'm think about billing E/M codes until symptoms are relieved, then code CPT 28080 (excision, interdigital [Morton] neuroma, single, each) or CPT 64776 (excision of neuroma; digital nerve, one or both, same digit) if the laser treatments fail to work. 


 


PM News Subscriber


 


Response: Why would you use a code for neuroma excision if you are not actually excising the neuroma? I think you may be asking for an audit, especially if the patient complains. Do you actually make an incision? If not, then you can't bill for one. If the laser treatment of the neuroma is off-label, be sure to get a separate consent clearly spelling this out for the patients. 


 


Vince Marino, DPM, San Francisco, CA


 


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11/22/2016    

CODINGLINE CORNER


Query: Coding Revision Surgery


 


I will be removing a Silastic implant from the first metataral-phalangeal joint, and fusing the joint with a bone graft. How do I bill the procedures? 


 


Jeffrey Klein, DPM, Waterford, MI


 


Response: I suggest CPT 28750 (arthrodesis, great toe; metatarsophalangeal joint). The removal of the implant is not separately billable because it is considered to be part of the dissection for the fusion. If you feel the extra work performed to remove the implant was substantial, you can add a "-22" modifier to indicate the work performed was substantially greater than what is typically required with this code. Submit the necessary supporting documentation. 


 


If you obtained the bone graft yourself from another site, you can also code CPT 20900 (bone graft, any donor area; minor or small [e.g., dowel or button]). CPT 28750 does not include the harvesting of the graft or implant from a separate site. If you used allograft, nothing should be coded relative to the use of that graft. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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11/19/2016    

CODINGLINE CORNER


Query: CPT 28510 Global Days


 


What is the global period for CPT 28510 (closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each) with Medicare? 


 


Danielle LaLonde, Belvidere, NJ 


 


Response: The Medicare global period is 90 days for CPT 28510. You can, however, bill any medically necessary follow-up x-rays you perform during the global period. 


 


Katherine Sharp, Woodbury, TN


 


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11/15/2016    

CODINGLINE CORNER


Query: Pre-Operative History and Physical


 


I billed CPT 99214 for a pre-op history and physical encounter since I spent about 30 minutes face-to-face with the patient. Now Medicare is requesting my notes. The pre-op visit was on March 31 and the surgery was performed April 2. I documented my start and finish time for the entire encounter, as well as the counseling time of 18 minutes. Did I code correctly? Is it reasonable to code CPT 99214? Should I change the visit to CPT 99213? Should I not charge for the pre-op which may or may not have a family member who will be caring for the patient sitting in and hearing about the procedure, complications, risks, and post-operative care? 


 


Codingline Archive Question


 


Response: The reimbursement for a surgery is calculated by taking into account the normal pre-operative care, surgery, and normal post-operative care. A normal pre-op history and physical encounter should not be billed in addition to the surgery. 


 


Medicare considers a one-day pre-op global fee period, so the reason you were paid is because it was 2 days prior to the surgery. If Medicare determines that it was a normal pre-op and they suspect that you did it 2 days prior so that you could bill separately for it, they will ask for money back on it - regardless if you billed a CPT 99213 or a CPT 99214. 


 


Don Self, Whitehouse, TX 


 


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