Recent content by sparkles1077

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    MDM, diagnosis points

    You would also need to see that each problem is treated or managed in some way. Per 95 guidelines: DG: The initiation of, or changes in, treatment should be documented.Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and...
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    Pain Management documentation

    Reply to Pain Management documentation There is no issue with typing the radiology report into the note. In the EMR, the radiology reports are pulled into the physician note all the time. The issue would be how you would count this into the E and M. If it is just typed and the provider does...
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    Modifier ST - relation to trauma and injury

    Fellow AAPC Professionals: I am seeing modifier ST appended to radiology services in the outpatient settings for patients who have had an injury. This is happening for United Health Care Choice Plus. Does anyone have any information on whether this is appropriate use of this modifier for this...
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    Billing for an Inpatient Stay

    Hello Fellow AAPC Coding Professionals: I am working on an audit and am not familiar with billing for critical access hospitals. A patient is admitted for five days and is seen by three different hospitalists. All five encounters are billed under the discharging physician. Is this correct...
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    How to code for "Cognitive Impairments"

    Thank you several years later!
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    Interesting use of EMR - any thoughts?

    Hello fellow coding professionals, So, got a client that uses the transcription/EMR combination. The HPI exam and MDM are dictated and then pulled into the note by the midlevel. The LPN completes the ROS and PFSH. The CODER (yikes) pulls the ICD codes into the assessment and plan. Each...
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    signature for each section of EMR

    Do you have a reference for MEAT? I have not heard of this before
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    emr hx reviewed by

    I think it is okay to accept because the provider documented in the note that he did review. The MA must have taken the history during initial intake and nothing has changed so it is still in the MA credentials. The provider indicated he/she reviewed, which is acceptable per 95 guidelines
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    Decision for Surgery within global period

    Hello Fellow Coding Professionals Patient had surgery for greater tuberosity fracture with shoulder dislocation and is in the office during the global surgery. There is a displacement of the greater tuberosity fragment and a decision for ORIF is made. Is this a billable E and M since the...
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    Hello Fellow Coding Gurus, So we are debating on the correct code for the following documentation: CAD (coronary artery disease) of artery bypass graft CABG was in 2003. No stents in over 1 year. Will hold Plavix and aspirin so patient can have port placed My thought was 414.04 because...
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    How to code E&M in office if patient not present?

    See the following link from AAP: At the bottom, they explain that the family member may be seen without the patient and the provider may code when time is...
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    Case #20 Winner, Answer Key, & Rationale

    Thank you for the challenges!! Keep 'em coming!
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    Ejection Fraction

    When coding for an E/M service, is a low ejection fraction considered high risk? Thank you