Recent content by sankoe@keystoneruralhealth.com

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    History of hysterectomy

    If its documented that a patient had a hysterectomy but doesn't indicate whether a cervical stump is left do you default to any certain Z-code ?
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    Question HPI vs A/P

    If the HPI states hypoglycemic episode and numbness in the feet but doesn't state anywhere in the HPI that the patient is a Diabetic and the A/P states DM with neuropathy is it ok to code it as such?
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    Question New Patient

    Patient had already had a preventative. We are a FQHC and are paid a PPS rate based on a face to face encounter with a provider. The doctors wants to receive the payment for the encounter but I don't feel this meets criteria for an office visit. The HPI is all about the mother the only portion...
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    Question Screenings?

    If a new patient comes in and the doctor discusses PSA screening. Would you use the ICD 10 code for Screening for Malignancy of the prostate even though at this time no lab is being drawn. Patient will be returning for a lab draw in the future.
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    Question New Patient

    When you are seeing a New Patient with no concerns just needs immunizations, what level E/M would you code? What HPI element could you count (location, quality, severity, context, etc.)? I need at least one to code even a 99201. HPI states: 12 Months Old 40 weeks. Maternal hypertension. No...
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    Question HPI

    So am I right to not charge an E/m at all.
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    Question HPI

    I have a "NEW" patient to our office with no new concerns or problems. They just need immunizations. HPI states: Patient due for immunizations. If any what HPI element is there? I cannot come up with one. Doctor wants to bill a 99203.
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    Question Preventative with positive rapid lyme

    I feel like its appropriate to add an additional E/M addressing patient complaint fatigue along with a preventative. Am I correct and after review I believe the E/M would be 99213 and also should the fatigue be updated to lymes disease since it came back positive since we have a definitive dx...
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    Shaving of epidermal lesion coding

    I just want confirmation that I'm billing this correctly. I'm second guessing myself. Patient presents for mole removal on left upper arm and right upper shoulder. Path came back intradermal melanocytic nevus D22.62 and D22.61 are the dx I will be utilzing based off pathology report. I am...
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    Osteoarthritis shoulder

    Debra thank you I did speak with the doctor and it was an error on his part.
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    Osteoarthritis shoulder

    The provider coded Primary Osteoarthritis, not myself. That's the reason for my inquiry as I wasn't sure if the documentation in the HPI was ok to apply the DX to this visit. So since the doctor specifically coded it in the A/P Osteoarthritis its all good. Fairly new at this so I just want to...
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    Osteoarthritis shoulder

    Hello! I have a physician that has documented in his HPI: Has had right shoulder surgery, with follow up with ortho later today David PA-C. She is having PT. Coded this a M19.019 Primary Osteoarthritis, Unspecified Shoulder History: Patients reason for surgery, repair of a rotator cuff...
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    History of

    Provider documents: Patient has a history of iron deficiency, chronic kidney disease, and an elevated alk phos level, all of which will need rechecked. She also is due to have cholesterol checked. Recheck lab work at this time. Provider codes as current conditions not history of. Would you...
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    Help!! Lymphadenopathy Not!

    I am at a complete loss on this one. I'm leaning towards a no charge for the fact that I have no definitive dx and/or no sign or symptom to code. Any suggestions would be great. cervical lymphadenopathy. Patient also reports right anterior cervical lymph node. She reports she noticed it...
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    Diabetes

    Note Reads: Patient here today for a recheck of swelling. She continues to have swelling. She reports it may be "slightly improved" since stopping Tradjenta. During last visit her Tradjenta was held. She is asking to stop her other medications including statin and insulin. She believes...
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