In Coding
Jun 19th, 2017
In the outpatient setting, do not code a diagnosis unless it is certain. Examples of language seen in the medical record that identify uncertain diagnoses include: Probable Suspected Questionable Rule out Differential Working When a definitive diagnosis has not been determined, code the signs, symptoms, and abnormal test result(s) or other reasons for the visit. ...
In Coding
Jun 19th, 2017
When billing for professional services, you should report 96372 Therapuetic, prophylactic, or diagnostic injection, specify substance, or drug; subcutaneous or intramuscular for each medically appropriate injection provided, as instructed in CPT Assistant (May 2010; Volume 20: Issue 5): Question: What is the appropriate CPT code to report when a patient receives two or three intramuscular ...
In Coding
Jun 19th, 2017
To determine what to include in the History of Present Illness (HPI), keep these questions in mind. Location – Where is the pain? Where is the problem? Ex. back pain, nasal congestion Quality – Please describe your symptoms (Action words) Ex. sharp or shooting pain, dry cough Severity – What is the patient’s level of ...
In CMS
Jun 12th, 2017
Medicare does not accept claims for either outpatient (99241-99245) or inpatient (99251-99255) consultations, and instead requires that services be billed with the most appropriate (non-consultation) E/M code. Report outpatient E/M services with the appropriate Outpatient Services code (e.g., 99201-99215, or 99281-99285 for patients seen in the emergency department). The service must be supported b...
In Coding
Jun 12th, 2017
You may report 69210 Removal impacted cerumen requiring instrumentation, unilateral if instrumentation is used to remove impacted cerumen. Impacted cerumen typically is extremely hard and dry, usually is accompanied by pain and itching, and can lead to hearing loss. Code 69210 captures the direct method of impacted earwax removal using curettes, hooks, forceps, and suction. ...