Here at Terry Fletcher Consulting, Inc., we get a slew of coding, billing and compliance questions on a daily basis. Our Coding Corner Membership clients send over their challenging questions when working in the Revenue Cycle Management department, and we are here to help. RCM can start at the front desk, to the patient exam room, to the back office, then into the coding and billing office. If we do our job right, we can minimize the claims that end up in the appeals office. Here are the questions and answers for the first quarter of 2025, that I hope may be of interest, and that may assist many of you in your workflows.

Here are our Top Ten Questions:

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For ICD-10, intermuscular lipoma on the flank, would you lean to D17.9 for intermuscular or specifically to the site for D17.1?

Answer: I would report D17.1 as it specifies skin and subcutaneous tissue of the trunk. When I search Lipoma –> intramuscular in the ICD-10 index it takes you to D17.9. This is a great way to start your search for specificity. Don’t stop there. Go to the D17.X and then add your details.

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I have a client looking to charge patients an annual administrative fee. While, this client is aware they can imposed fees for completion of certain forms including school, work, camp, jury duty, disability forms not connected with the providing of covered services, missed appointment fees, and charges for copies of medical records when the records are being processed for the subscriber or member directly, they are wanting to roll out an annual admin fee to all patients.

Answer: I believe this violates participation agreements with most payors, including CareFirst, UHC and some BC/BS plans. There is a cost of doing business wrapped into the RVU.PE (physician expense) in each CPT® code. This would be inappropriate to try and enforce.

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I would like your opinion on the following scenarios of billing imaging during 27245 – Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage.

It is understood that 76000-26 is not billable with 27245 (although we have had instances where it has been paid as 76000.26.59, and I believe we should refund that payment).  NCCI also clearly states that 73503-26 is not allowed. There is discussion whether 73502-26, or 73503-26, are billable if views of the fluoroscopy are taken during the surgery and the interpretations are documented in the operative report. I do not find that the specific codes are disallowed, but the September 2013 CPT® Asst Q&A states that all imaging performed and interpreted during the case is included in the 27245 (see the attachment).  I had another article from CPT® Asst that also confirmed that 73503 was not allowed with 27245, but since CPT® Assistant has been moved to Find-a-Code®, I am having problems finding it other than the below from NCCI edits.

Answer: I do agree that imaging is inclusive. The reason that AMA® has indicated that it is included in the surgical procedure is due to the fact that it is not being done diagnostically. When we look at the category for 73502/73503 they are in the diagnostic radiology section. The descriptions are also “radiologic examination” not fluoroscopy. The documentation of the op report and the performance of the imaging is not for diagnosing the patient; it is checking alignment and placement of hardware; therefore, it is inclusive to the procedure. I have the same issue with cardiologists and IR docs trying to charge for pre- and post-angiography to “set up the procedure or measure the vessel”, and then image post procedure, to “check their work” or stent placement. Again, that is inherent to the procedures, and not diagnostic, and thus not billable in addition to the major procedure.

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If a physician sees a patient in the office in the morning for a new condition and again in the afternoon because the condition has worsened, should modifier -25 be appended the afternoon visit?

Answer: No. The physician would be expected to combine the documentation of both encounters and bill one E/M based on the combined documentation. Modifier -25 would not be appropriate for this scenario. Modifier -25 is used to identify a significantly, separately identifiable E/M service performed by a physician on the same date as a procedure or other service. (Novitas. E/M FAQ)

If the same provider (or different providers of the same specialty and subspecialty belonging to the same practice) see a patient more than once on the same date of service in the same setting, CPT® has also clarified in the 2023 E/M update that you’ll submit just one E/M code, using the following criteria:

• When using medical decision-making (MDM) to select the code, you’ll aggregate all MDM from that date of service together and use that to level your service.
• When using total time to select the code, you’ll add the times of the two visits together to find the most accurate E/M level.

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Can two physicians in the same group practice, who see the same patient on the same day, each bill for an E/M service and receive payment?

Answer: Physicians in the same group practice but who are in different specialties may bill and be paid separately without regard to their membership in the same group.

However, again, physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.

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How is medical necessity considered when scoring medical records?

Answer: All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, “…no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member.” Therefore, medical necessity is the first consideration in reviewing all services.

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Is it acceptable to use abbreviations in the patient’s medical record?

Answer: Abbreviations may be used in the patient’s medical record. If your patients’ medical records contain abbreviations not commonly used, and you receive a request for medical records, please provide a key to the abbreviations. Submit the key with the medical records to assist us in the review. (V/U = verbal understanding or P/D = patient discussion are not typical to medical records acronyms). Also remember Googling does not always give you the answers.

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MDM Q&A from MAC Novitas provider meeting asked, “If I personally review a film, e.g., x-ray, electrocardiogram in my office, will I receive credit in the amount and complexity of date to be reviewed and analyzed?”

Answer: Credit may be given when a practitioner independently visualizes an image, tracing or specimen previously or subsequently interpreted by another physician. The medical record documentation must clearly indicate that the physician/qualified NPP personally (independently) visualized and performed the interpretation of the image, tracing, or specimen. Credit will not be given if the documentation reveals the practitioner only read/reviewed a report from another physician/qualified NPP.

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When a patient presents to an emergency department prior to midnight and the physician sees them after midnight, which date of service do we report?

Answer: The date of service would be the date the physician performs a face-to-face service with the patient. If the service started on one day and carried over continuously through midnight into the next day, the date the service began is the date of service when the face-to-face started. If the physician did not see the patient until after midnight, the date of service is the date of the face-to-face encounter.

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Can you help us with MIPS to determine what we need to do?

Answer: No, MIPS (Merit-based Incentive Payment System) quality measures calculations and algorithms are very complicated, and I like to stay in my lane of coding, auditing and education. However, in saying that, you can also go through your EMR vendor (EPIC or NextGen or Cerner, etc) for MIPS. They can run you a report to determine which provider is eligible for MIPS and will also be able to identify what measures need to be performed for that particular specialty.

Since you have to pick certain ones based on the volume of what that individual provider does, then the practice, start there and that should help.

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Check back with us quarterly as we will be posting our Top Ten Tuesday podcast sessions as white papers. Don’t forget to listen to and subscribe to our CodeCast Podcast found on all platforms. New episodes drop every Tuesday.