Office Procedures – Document and Code Them Right

Coding for procedures done in your office depends on understanding the criteria for the procedure. Surgeons commonly excise lesions, perform biopsies, and do laceration repairs in their office and other outpatient settings. Often, EHR templates fail to prompt you to document key information to support the code. When insurers ask for records or you file an appeal—the missing details result in no payment. This session walks you through examples of solid documentation for office procedures and appropriate use of modifier -25 and discusses diagnosis coding that establishes medical necessity for the service.

Accreditation:

The American College of Surgeons designates this enduring activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Of the AMA PRA Category 1 Credits™ listed above, a maximum of 1 credit meet the requirements for Self-Assessment.

Learning Objectives

As a result of this course, participants will be able to:

Document office procedures based on the CPT requirements
Select the correct codes for office procedures
Be confident when to bill for both an office visit and a procedure and use modifier -25

What's On the Agenda

Lesion Excisions

Measuring lesions
Benign lesions
Malignant lesions

Excision of Soft Tissue/Bone Tumors
Skin Biopsy
Fine Needle Aspiration (FNA) Biopsy
Repair (Closure)
Hemorrhoidectom
Modifier -25