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    Coding Overactive Bladder as Chronic Condition with Rotator Cuff repair

    Well said Thomas! In a perfect world the coders would receive this information BEFORE they start coding for any health system.
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    Question Lap surgery help, please.

    I would look at 49002.
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    New coder / Question about documentation

    Previous chart notes when coding surgery Hi Debra, If a provider links with date and signature, the H&P that was done when the decision was made for surgery and it is less than 30 days old, can you use it for additional diagnosis coding when the operative note does not include chronic...
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    Moderate MDM

    "Management" vs "Writing 7-10 day Rx" Mod risk? Having experienced a CMS audit of E/M services, I can tell you flat out with certainty that CMS does NOT consider writing a script for a 7-10-14 day Rx "prescription drug management" in all cases and an automatic "moderate" risk. The...
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    Auditing Using 1995 Guidelines

    Exam 1995 DG's - additional question/info??? Hello all, I LOVE Tessa's idea of having the provider define his/her single system exam for the record and filing it in your compliance plan. However, many of us are responsible for auditing hundreds of providers from multiple health systems. Any...
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    Charging ED visit and admission/delivery same day

    Hello all, I have a client (large hospital system) that bills for an ED visit when seen by an OB Triage provider when they are admitted the same day for active labor and delivery occurs. Does anyone know if this is kosher? Wouldn't the "ED"/Triage provider's evaluation that the patient is in...
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    Laparoscopic cholecystectomy with failed cholangiogram

    47562 I would not bill at all for the failed procedure. You will get reduced payment for the completed lap choley if you amend either the 52 or 53. Neither of which is appropriate in this case. Not done, not done. Best of luck. Anita Johnson, CCS, CCS-P, CPC, CPMA
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    lazy susan two sided coding book stand

    Yes!!! I am very interested in the book stand. I know many of the coders here will be as well. Can you give me the specifications including size, color, price and shipping costs? Thank you. Anita Johnson, CCS-P, CPC, CPMA coder925@gmail.com
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    *** New Opportunity for CPC's!

    Dear Certified Coders, Here's is a new job opportunity: Position Categories ** Medical Coders - CCS, CPC, CPC-H, RHIT, RHIA with 2 + yrs expertise. Pay ranges $15.00 - $30.00 per hour ** Medical Transcriptionist - Recent graduates & highly experienced transcribers. Pay ranges $0.07 - $0.15...
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    Could use some help on general Surgery note 3

    76098 is all you are missing The provider looked radiologically at the specimen(s). Good luck on the next round!
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    Could use some help on general Surgery note 3

    Last Code! hI. You are missing the code for examining the specimen under xray. Try adding 76098. Thanks. AJ
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    Appendectomy Question

    Peritoneal implant? This is an operative note I would like to see in full. Please forward to my email? Thanks.
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    Tips for CPMA Exam

    CPMA Study Buddy Thank you so much for the tips. I have yet to locate a "study buddy", but I did receive some additional materials to study from a colleague. I will heed your advice as well and hopefully pass the exam on the first try. Once again, my thanks.
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    Excision of Gastrocutaneous Fistula

    Fistula Why not 43880?
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    Tips for CPMA Exam

    Study Buddy for CPMA Amy, I am taking the test in November. Would you like to help each other long distance? I am trying to get a group started. Send email if interested. Thanks. Anita
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    Mental Health diagnosis

    Bully How does it manifest itself? anxiety? 300.00 panic disorder? 300.01 panic disorder with agoraphobia 300.21? I would query the provider. Good luck.
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    Medicare and Mental health

    H2010/90862 No, they are not. H2010 is included in 90862 but is specifically for use when providing services to one with alcohol and drug treatment issues. 90862 is for general purposes. Good luck. Hope that helps.
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    Let's start a pysch coding email group!

    Yes! Please include me, too. I have been coding IP Psych for about 6 months now.
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    Using icd 9 codes in assessment!

    Really good question I am going to pose this question to my auditors. More to come. Thanks for the question. Anita
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    When do you have "High" MDM in Psych?

    BH MDM Table of Risk? Could you please send it to me also? coder925@gmail.com or fax: 321-843-3553 Many thanks.
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    Admission Notes

    99221-99223 I use the IP admission codes for my M.D.s.
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    Wiki Pain Disorder diagnosis code?

    Chronic Pain Yes. I also use 338.29 for chronic pain issues.
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    Orthopedic Pick list for ICD9

    :)Hello, Does anyone out there have an ICD9 pick list for ortho? I am brand new to it and I find a pick list can atleast get me in the right neighborhood when looking for a code. If so, please email it to: coder925@gmail.com or send it to my private fax: 321-843-3553 I would appreciate it very...
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    E/M Audit

    1997 E/M Audit tool :) I would love a copy too. Thank you. coder925@gmail.com Anita
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    E/M pocket tool

    Pocket Tool :) Hi! I have a few of them. Are you looking for any particular specialty? I have a general one for the 95 guildelines if you want that. Just send me your email address. coder925@gmail.com Anita
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    1997 Guidelines Check list

    Hi!.:) I was wondering if anyone had a table or check list for the 1997 guidelines, musculoskeletal exam. I am going crazy trying to pull those bullets out of my dictation. Thank you. Anita
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    established problem worsening

    worsening Perhaps she/he sees the problem as worsening because she has now been infertile for three additional months with no pregnancy. Just a thought.
  28. A

    established problem worsening

    worsening Perhaps she/he sees the problems as worsening because she has now been infertile for three additional months with no pregnancy. Just a thought.
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    Behavior Health Audit Tool

    MDM Behavioral Health Info Are you still taking requests? If so, please send a copy to: anita.johnson-schoonover@orlandohealth.com Thank you......
  30. A

    Repair of Rectus Diastasis

    Ventral Hernia My doctor says to bill it as a ventral hernia, so I do. Good luck.
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    Internal hemorrhoidectomy only by excision

    46260 Hello. With 46260 I interpret the word "and" to mean "and/or". I would use it for your case without any modifier. Unlisted codes are a headache. In your case, 3 columns qualifies. Good luck.
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    Colonoscopy follow up visits???

    24 modifier You will need the "24" and I agree that a separate E/M can be coded for colonoscopy result discussion. Good luck.
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    procedure discontinued

    43770-53 I would code the 43770 with a 53 for discontinued procedure. This allows you to bill it again once you complete it. I don't see how you could bill for iatrogenic perforation repair at all. Just the attempted lap band and the liver biopsy 47001. Good luck.
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    Rosie, CPC

    44626 I agree with 44626. My experience with modifier "22" is that the provider must specify exactly what made this procedure above and beyond the "norm" in 80 characters or less. They must say what is normal and how long or with what special skills they have that require special consideration...
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    power port placment

    Agree with SS62 I agree that the dx to be used is the dx for medical necessity for the procedure. What CPT code are you using?
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    bill 99232 twice

    Only once... Hi! You can bill for only one of them. I would choose the one with the highest level to submit for payment. If they both did a level two you have to draw straws. Good luck. Anita
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    E/M Specilaty Exam

    E/M Coding Exam Hi!. I took the exam twice and failed. It was very hard. I suggest practice. If you have a senior coder at work, I would ask him/her to audit your work. Take your favorite audit tool to the exam. I found it to be much harder than the practicum. Good luck! Anita
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    99239 & 99291

    Stick with the critical care I would bill the critical care code only. It pays better and you will not be allowed both if it is a Medicare claim. Good luck! Anita Johnson, CPC, CEMC
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    Problems to exam physicians?

    *Etiology Unknown Your scenario as it reads to me would count as a new problem to the physician and credited thusly. You can err on the side of caution if you wish, but, you cannot assume from that note that it is self-limiting. 3 points! Thanks for listening. Anita
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    critical care time

    99291 & 99292 q3 I agree with Michelle. You get the 99291 for 74 minutes, leaving 96 min. You get 99292 for the next 90 minutes leaving 6 minutes. The minimum threshold for 99292 is 15 minutes, therefore the last six minutes are a wash. Thanks for listening. Anita Johnson, CPC, CEMC.
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    Mdm

    Higher than what? It wouldn't automatically qualify for a higher level of MDM. You must still use the Table of Risk which would most likely be low risk for a cold, even for an infant. Sorry.
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    Any CEMC's out there?

    Hi ! I am sitting for the CEMC exam in two weeks and am wondering if there is anyone willing to offer me a little advice before the exam. I read in the AAPC practicum materials that the exam doesn't require it's examinees to render any opinion as to Medical Necessity. Is that true? Any sage...
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    Return hops with in two to three days

    Your doctor is right The patient only has to be home 1 calendar day to be re-admitted. If the patient is discharged at 6:00 p.m. and is readmitted after midnight, your physician can perform and bill for another H&P. You only find restrictions in writing, rarely permissions. And always be wary...
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    99214 versus 99221

    99221 if he meets the criteria Hi. I dont see 4 elements of HPI to qualify for the 99214, however, that point is moot. If your provider admitted the patient on the same day as the office visit, all of the office services are included in the hospital admit code. You can bill the 99221 with the...
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    Chief complaint-I recently read

    CC can be in the HPI You can pull the Chief Complaint from the HPI. If your doctor discusses 3 chronic illnesses for example, or states that the patient is "feeling tired". Then choose your level of E/M from the appropriate section based on the rest of the note. Best wishes.:)
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    Injection at office, then initial hospital care

    Give it a try! According to CPT and Ingenix " All services " are included in the admit code. However, it is vague at best. You could try billing the injection with the modifier 25 and see what happens. Good luck!
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    Simple question - I promise!

    You sure can! The neck is recognized by both sets of guidelines as a body area. Per the 1995 guidelines, your physician's statement would qualify as 1 body area/system. Best wishes!
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    Two E/M Codes On The Same Day

    Yes you can Yes you can. Just be sure that the ICD-9-CM codes justify each service. It is billable without modifier. Good luck!
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