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04/05/2021
Question: What’s the difference between modifiers 52 (Reduced services) and 53 (Discontinued procedure)? They seem pretty similar, because in both cases you stop part-way through.
04/05/2021
Question: I am not sure how to set the risk level when a physician refers the patient for possible surgery that will be performed by a different doctor. For example, an orthopedic surgeon sees a patient with Dupuytren’s contracture and discusses the treatment options — Xiaflex injection or fasciectomy with the patient. Please help.
03/29/2021
Question: Our practice does not have electronic health records (EHR). Instead, we keep paper patient records. I understand the new information blocking rule that goes into effect April 5 requires that I give my patients their protected health information (PHI) in whatever format they request. Will I be in violation of the rule if I can only give them paper?
03/22/2021
Question: I’ve been seeing a lot in the media about cryptocurrencies, such as Bitcoin. They seem to be getting more popular. Should I offer to accept cryptocurrency for payments?
03/15/2021
Question: We are struggling to get our providers to document whether the problems they are treating are acute, chronic or acute on chronic. I have not found a guide or publication that instructs coders what to do if this important information is missing except to query the provider. This is causing a lot of upset within our office and I’m wondering if this is one of those issues for which we should create our own internal policy for documentation?
03/08/2021
Question: I diagnosed a patient with a seizure disorder. I told her to report the diagnosis to the Department of Motor Vehicles (DMV) as it may invalidate her license; I’m pretty sure she won’t do it. If I report her to the DMV myself, am I violating her confidentiality?
01/25/2021
Question: We have patients who can’t take part in an audio/visual telehealth visit, which is currently allowed under the COVID-19 rules. We understand we can report telephone-only visits, but the Drug Enforcement Agency (DEA) requires a real-time, two-way, audio/visual encounter when the doctor or treating practitioner writes a prescription for a controlled substance.
01/25/2021
Question: One of our doctors failed to review and sign the encounter notes on some of his visits — and then, unfortunately, he passed away. Can we bill for the visits?
12/07/2020
Question: Our surgeon did a knee replacement on a patient, which put her on a walker and crutches for an extended period of time. Using the crutches caused her back pain, and she saw the surgeon about it. Can the surgeon claim an E/M with modifier 24? Or is this considered a “related” condition?
10/26/2020
Question: A patient with a history of hypertension and high cholesterol visits a cardiologist for an appointment, complaining of occasional chest discomfort during exercise. After the physician completes an office visit, it is determined that the patient needs a cardiovascular stress test, which is performed that day by the same physician. Would it be appropriate to report an E/M code for the visit with modifier 25 (Significant, separately identifiable E/M)?

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