Recent content by MikeEnos

  1. MikeEnos

    Help with HPI points for new patient

    The phrase "here to establish care" tells you that this is an annual preventive exam, not a "sick visit." There is no sufficient chief complaint or HPI to support a sick visit.
  2. MikeEnos

    CPMA CEUs: how do I get them?

    I signed up for the yearly webinar subscription from AAPC. The good news is they have a wealth of webinars that will get you your CEU's in no time, and they're great material. The bad news is that I keep adding them to my CEU tracker, and for some reason they are counting towards my CPC but...
  3. MikeEnos

    MDM - Manangement option

    Yes, I use the list tony provided. His link didn't work for me, try this one If that doesn't work, this will. Just do a Google search, it's the first result.
  4. MikeEnos

    HPI Question

    This same question was asked a few weeks ago. In fact, the same example (cough) was used. My answer even includes a mental disorder being located in the brain. Here, I'll copy and paste it for you:
  5. MikeEnos

    Rx Drug Management

    Prescribing a new medication absolutely counts as prescription drug management, along with the other things you mentioned (increasing/decreasing dosages, refilling or stopping a prescription.) Think about it. The provider doesn't just write down a prescription without giving thought to the...
  6. MikeEnos

    Exam

    I agree with Tony. I don't see how anyone could differ, CMS is unambiguous on this. According to CMS: So yes, as long as they aren't seeing the doctor for a problem with their Eyes, Earns, Nose, or Throat, you can give credit for the statement HEENT: normal as review of the Head, Eyes, and...
  7. MikeEnos

    E&M Level for Orthopaedic Est Pt

    Regardless of whether you feel the Medical Decision Making was Low or Moderate, you don't qualify for a L4 new patient visit, because you don't have a comprehensive history. For an established patient, you would qualify as L4 because you have at least a detailed history and exam, so depending...
  8. MikeEnos

    New patient

    According to CMS: So yes, assuming they have documented the total length of the encounter, that greater than half of it was spent counseling, and the content of the counseling, they can bill the E/M visit based on the time. It doesn't matter what level of history, exam, or medical decision...
  9. MikeEnos

    chart note abstracting

    The contractors I've asked have not accepted 'inferred' location. Meaning you can't just infer that the location of depression is the brain, or the location of asthma is the lungs, or hypertension is the heart, etc. For some problems you can get a location (left knee or right thumb) but some...
  10. MikeEnos

    What level?!? ASAP

    Well no, it isn't a 99204. You don't have a complete review of systems, means you can't have a comprehensive history. The blurb at the bottom about time doesn't cut it, either. It's a bit confusing but all it gives us is the total face-to-face time. In order to select the level of service...
  11. MikeEnos

    E&M auditing tools

    When I'm training providers on E/M, I usually show them the requirements of the common codes they will use, then walk them through an audit tool. Here's a free one. And here's an E/M pocket reference I made.
  12. MikeEnos

    Use of an interpreter

    You would have to check with your local carrier. Some do not give any complexity, believing that a translation is more of a tool being used and doesn't add complexity. Others (rightly, in my opinion) factor in that use of a translator does add complexity and time to the encounter, as the...
  13. MikeEnos

    Comprehensive HX for a Newborn 99222

    Regarding Medical Decision Making, you can pretty much just use the same tools (Marshfield Clinic) we use for adults. Granted, you should keep in mind the complexity and risk that the provider is dealing with since it is a newborn who requires admission, but I don't think there are any...
  14. MikeEnos

    e/m levels for non verbal

    Agreed. If the provider documented the length of the encounter, and how he counselled the parents/caregivers.... or documented getting history from someone other than the patient... or even documenting what review of systems he can ascertain, then stating that the rest of the ROS was...
  15. MikeEnos

    Thank you, and 2 free E/M coding references

    Hi everyone, I just wanted to say thanks to all of you who participated in the beta test and helped by giving me your feedback. I really appreciate your hard work! The beta test is now completed, so I just wanted to let you know that I don't need any more volunteers at this time. To give...
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