00029754

Neurologist is seeing a patient for followup of radiculopathy and neuropathy. She performs a neurological exam including cranial nerve exam, motor exam, sensory exam, coordination, and gait exams.

Under motor exam, she has a table/grid containing numerical values for each muscle strength tested. Is this information enough to assign CPT 95834? Not sure if this grid of numerical values per muscle constitutes a 'formal written report of the findings' that CPT Assistant references must be present in order to code this. (CPT Assistant, December 2003 Page: 7 and , November 2001 Pages: 4, 5). Otherwise, this manual muscle testing is included in the Physical Examination component of the E/M. Neurologist has coded E/M 99213 only but was wondering if the motor exam could be coded separately with documentation of the grid values per muscle.

Can I code and patient with active cancer if the pet scan shows no cancer present and is not actively receiving chemo or radiation treatments

In an Outpatient physician office setting, it is my unerstanding that although Medicare will not cover telephone visits by a physician, they should document as a visit because time spent on them may be used in determining the next face-to-face visit level. Is this true? I heard this from colleagues and I also read it in this amednews article. http://www.ama-assn.org/amednews/2010/02/01/bica0201.htm#relatedcontent
It states that this is a CMS rule, but I can't find anything in CMS guidelines that states this. Is it implied somehow? Any help would be greatly appreciated! Thanks!
Lora CPC

I am a new member and I'm in need of Infertility codes for ICSI and assisted hatching...Any information will be gratefully appreciated.

Thanks,
Phyllis

I have a question about chart audits for EMR. I just started working for a Urology grp that is using EMR. They are not using the EMR in it's full capicity. The example of which is they are not using templates for E&M evaluation. They depend on dictation for notes. I have been hired to preform internal chart audits. I was hoping you could help me with finding documention for auditing an EMR record.The doctors are stating in there dictation that all PFSH and ROS has been reviewed and updated in EMR. I have no notation proving that all were updated & reviewed. They had a rep from MEdicare tell them that all they had to do was state in dictation that is was reviewed. I have preformed Audits before, I know I need to see the documentation. These Doctors want proof that it had to been written in other then just a dictated note. Please help.
Thank you
Maria Oatman CPC

I have some doubts relating to the number of codes that are present in ICD-9 to ICD-10 code conversion GEM file.
But I wonder that there are only 33356 ICD-10 (unique codes) codes mapped to 13K+ I-9 code in the GEM file in place of the total available 68K I-10 CM codes.

Can you please let me know why is this and where are these rest 35K codes lying and is there any mapping (forward) available for those?