Coding For Multiple E/M Services and an Injection

How strong are you at coding for multiple E/M services? Test your knowledge and see if you can determine the right way to code this scenario. Hint: There are CPT, HCPCS, and ICD-10-CM codes needed.      Question:  A 51-year old female patient is seen for a follow-up visit for her seronegative rheumatoid arthritis that […]

Craniotomy to Evacuate a Hematoma in CPT

Selecting the most specific code for a craniotomy to evacuate a hematoma in CPT comes down to the documentation, where the hematoma is located, and the approach taken to treat it.  Question:  A patient suffers an extradural hematoma in the supratentorial region of the brain, and the neurosurgeon performs a craniotomy to evacuate it. What CPT code […]

CPT Coding for Psychotherapy for Gender Dysphoria

In this coding scenario, you will learn one patient’s experience with gender dysphoria and how to assign the correct CPT code for psychotherapy for gender dysphoria based on who was involved in the counseling and how much face-to-face time was spent.  Question:  Patient with gender dysphoria is seen for psychotherapy today due to feelings of anxiety […]

Vestibular Evaluation for Dizziness

Question:  A patient with complaints of dizziness is seen for a vestibular evaluation. The physician completed the following tests: spontaneous with gaze, optokinetic, oscillating tracking, positionals head right and left, and Dix-Hallpike right and left. The physician also completed warm and cool caloric irrigations in both ears, for a total of four irrigations. All tests were performed […]

DaTscan to Differentiate Between Parkinson’s and Essential Tremor

When the neurologist has ordered several imaging tests and is still unsure of the diagnosis, it may be time for a SPECT brain DaTscan to differentiate between Parkinson’s and essential tremor. Question:  A patient who has not been responding well to dopaminergic therapy is considering deep brain stimulation surgery. The patient has had several imaging scans […]

Sacral Neuromodulation /Stimulation Procedure Coding

Knowing the correct CPT code for a neurostimulator procedure can be tricky if you don’t know the staged procedures and temporary vs. permanent placement. Follow along and I’ll explain sacral neuromodulation /stimulation coding for this scenario.    Question:  A female patient with interstitial cystitis is being seen by her urologist for percutaneous implantation of a […]