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Coding for Ambulatory Office Procedures
Coding for Ambulatory Office Procedures
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Pdf Summary
The document is a comprehensive guide on coding office procedures, emphasizing the importance of accurate medical coding for reimbursement and adherence to regulations. It is authored by Charles D. Thompson, MD, a specialist in Urogynecology and Reconstructive Surgery at Texas Tech University Health Sciences Center. <br /><br />The content outlines key aspects of coding for office procedures, including the use of relevant modifiers, understanding global time frames, and navigating CCI (Correct Coding Initiative) edits. The document also highlights the significance of preoperative, intra-operative, and postoperative components in coding, which the Centers for Medicare & Medicaid Services (CMS) scrutinize seriously.<br /><br />Global time frames are categorized for various procedures, with some procedures having a zero-day global period, such as biopsies and pessary placements, while others may have a ten-day global period, requiring at least one follow-up visit.<br /><br />Key sections of the document discuss the separation of Evaluation and Management (E/M) visits from procedures, the use of modifier -25 for office procedures performed alongside E/M visits, and the complexities involved when doing multiple procedures, advising the use of modifier -51 for multiple procedures.<br /><br />Specific coding examples are provided for procedures like pessary insertion, cystoscopy, and sacral neuromodulation, each with associated CPT codes and billing guidelines. There's an emphasis on the correct pairing of ICD-10 codes with CPT codes to ensure reimbursement, and the necessity to produce separate documentation for E/M and procedure codes when performed simultaneously.<br /><br />The guide stresses doing the medically right thing for patients despite the complexities of the coding process, and recommends employing coding software to assist in determining procedure bundles and RVU values. The overall aim is to enhance coding accuracy, ensuring proper claim submissions and financial reimbursement.
Keywords
medical coding
reimbursement
office procedures
Charles D. Thompson
global time frames
Correct Coding Initiative
modifier -25
modifier -51
CPT codes
ICD-10 codes
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