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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 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

    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

    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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    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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    Note reads! Patient presents weak and tired since this morning, very thirsty, dry mouth. Glucose in office 68, hypoglycemic. Does not check glucose at home and does not adhere to diabetic diet. Diabetes with good control on oral meds. Complications of ckd3 A1C 6.5 How would you code this?
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    FQHC E/M for VFC encounter

    I have a question. Our provider wants to bill an office visit 99212 when administering VFC vaccines such as the flu shot. We brought up the issue of medical necessity and also that a 99212 is a problem focused e/m and the patients only coming in for the vaccine with no problem. He just wants...
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    I'm curious if coding Z12.31 with an E/M is appropriate my provider, patients PCP, is referring patients for a Mammogram Screening and utilizing Z12.31 as a DX in his A/P. I do not feel this is appropriate since we are not actually performing the Mammogram. What do you think?