Recent content by purplescarf23

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    HELP! Can the Diagnosis be documented anywhere in the note or only the MDM?

    Thank you for your reply. So if this is the case then each section/components of the E/M level does not need to stand on its own? Wouldn't that sort of be double dipping to make each section 'complete'? Do you have something written that it would be OK to allow this? My place of employment...
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    Auditor states drug ordered as IV over 2 minutes must have a doc stop time?

    When its just an IV PUSH there does not need to be a stop time. If it truly was an IV drug hung for say 20 minutes yes there would need to be start and stop times but the PUSH IV drugs do not need the stop time. Here's a snipped from the encoder we use. Physician or other qualified...
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    HELP! Can the Diagnosis be documented anywhere in the note or only the MDM?

    Good morning, I've always been instructed (for over 12 years) that the diagnosis MUST be documented in the MDM portion of a chart note. Even the guidelines cover this in that section and don't address it in other sections of the E/M. However I have a few Vascular providers pushing back that...
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    Documentation requirements for 'reviewing' EKG's, etc.

    Good morning members. I am searching for information on what must be documented to prove a provider 'reviewed' an EKG, lab, X-ray etc. My company is trying to establish guidelines for our providers and I'm struggling to find a 'guideline' on what should be documented to support this. We have...
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    family history

    I would not use the family history codes unless the provider documents them 'somewhere' in the current note. Somewhere meaning anywhere in the current note. Each document stands alone, UNLESS the provider wants to refer to his initial note with the date and where it can be located, then you...
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    systems vs areas

    Yes I would count this under the respiratory organ system. Kelsey, CPC, CEMC
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    Cpc, cemc surgical coder-gen surg, ortho, etc

    Hi my name is Kelsey and I am putting my resume out there to see what options I may have for a remote position. I currently reside in Woodburn, OR and work remotely for a hospital in Longview, WA. Specialties that I am familiar with are General, Breast, Thoracic, Colorectal, Vascular, and...
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    Modifier 76,78,79????

    Where was this procedure performed? Generally if they are in the office we would use -58(related) but if taken to the O.R. -78(unplanned return to O.R.). The -76 is for repeat procedure on the same day. Hope this helps. Kelsey, CPC, CEMC
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    Use of Mod 58

    I would bill -78. Generally billing -58 indicates that this was a 'planned' return to the O.R. and I am assuming this was not. 58-Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure...
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    dislocation total shoulder

    I would agree with the 23655. That is what we use. :) Kelsey, CPC, CEMC
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    spacer exchange Total Knee

    We bill 27486-52 here in Washington. I have searched high and low and our COSC coder stated to use the above :) Hope that helps. Kelsey, CPC, CEMC
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    need help with observation H&P

    I work these type of scenarios everyday. Below is my opinion. 1. Can I use the office note for H&P for the observation service if the doctor doesn't refer to it in his documentation for the visit in hospital? The provider can 'refer' to a previous note with date and who's note in the past...
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    help with elements

    Note reads: patient presents with rash(chief complaint), swelling(associated signs), redness(quality), warmth in right arm(location). The patient has a fever(constitutional ROS), no N & V(GI ROS), is SOB(respiratory ROS), has had a blood clot in leg while pt was in ICU, has a hx of breast...
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    e&m cardiology audit

    I would give credit for 2 data points with this. I see this all the time with my cardio providers. Kelsey, CPC, CEMC
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    Cpc, cemc-multiple specialty experience

    I currently reside in Woodburn, OR and work remotely for a hospital in Longview, WA. I am looking for a remote position but willing to come into the office occasionally if office/hospital is within 45 minutes to 60 minutes one way. Specialties that I am familiar with are General, Breast...
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