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    Icd 10 for past history of needle stick?

    Provider documented only: "During her career, she has had needlestick injury. Unsure if she had had Hep B vaccine. Has not been tested for hepatitis C." Provider ordered labs, incl Hep B,C, RPR, and HIV. No documentation that she'd ever actually been exposed to bodily fluids. Tatoos don't...
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    Has anyone here ever been involved in practice start-up?

    Looking for some guidance in setting up a new primary care practice. Cannot afford to hire a "start-up consulting firm", just really need some suggestions for resources for policy and procedure templates, and the like. Any suggestions appreciated! Excited to be doing this, but today, feeling a...
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    Coding Hypothyroidism in Hashimoto's

    In researching Hashimoto's, I came across an article that said not all patients with Hashimoto's develop hypothyroidism. The chart I am coding this morning documents Hashimoto's disease, pt started on Nature-Throid. Do I want to code both the Hashimoto's and Hypothyroid? TY!
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    Wiki Coding GERD with Barrett's esophagus

    This seems like a really simple question, but I can't find an answer! When documentation states GERD and Barrett's Esophagus, are they coded separately or does it code to GERD with esophagitis? Thanks for your help!
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    Looking for opinions on how to handle erroneous code selection through EMR

    Good afternoon; I am just wondering how everyone else handles the issue of providers who choose incorrect diagnosis codes through the EMR system. Perfect example, I just came across in a chart note from October 2015: "Assessment: 1. Neoplasm of uncertain behavior of right...
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    PFSH in EHRs

    The EHR program we are using does not reflect who actually entered the PFSH in that portion of the chart, even though the provider does it at the new patient visit. In order for PFSH to be "counted" for New Pt E/M, doesn't the provider have to actually document in the note that he/she...
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    EHRs and PFSHx

    The EHR program we are using does not reflect who actually entered the PFSH in that portion of the chart, even though the provider does it at the new patient visit. In order for PFSH to be "counted" for New Pt E/M, doesn't the provider have to actually document in the note that he/she...
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    Physician erroneous diagnosis

    When reviewing chart notes to provide dx codes to the lab, I came across a note where physician "A" reported a rule out dx in his chart note. Physician "B" saw the pt in f/u 6 weeks later, as physician A is no longer with our clinic, and documents "Review of the records indicates (pt name) has...
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    Wiki Discomfort vs Pain

    Ok, here's a stupid question for a Friday am: Primary Care SOAP note documents subjective "...c/o dark, frothy urine" and "...vague complaint of left testicular discomfort." Physical exam documents "...normal testicles, possible some varicosities on the left..." When queried for more...
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    99211 for weight cks for anorexic

    I've been researching 99211 for hours now, looking for guidance whether or not to bill 99211 for provider-ordered Nurse Visit weekly weight checks for patient w/ dx of anorexia nervosa. Any thoughts?
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    DSM vs ICD 9

    I am confused by DSM vs ICD 9 dx codes for child sexual abuse. DSM says to use 995.53 if the patient is the victim and to use V61.21 if patient is the perp. It has always been my understanding that ICD 9 995.53 is for current, recent or active abuse; and V61.21 for history of child abuse...
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    Coder/Biller vs Biller/Coder

    How does a coder become a biller, as it appears billers are expected to be coders, as well and many more positions are available as such. Coders. per se, do not seem to be much in demand except in in-patient settings :confused:
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    Child abuse code vs Counseling for Victim of child abuse

    Any thoughts on when to use 995.50 Child abuse vs V61.21 Counseling for victim of child abuse? Is it as simple as: if the patient is 17 yo or younger (per ICD 9 guidelines), then use the 995.50, but even if the abuse occured several years ago? DSM says to use the 995.5x if the patient is the...
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    Chronic residual limb pain

    Any ideas? Documentation states: "Chronic residual limb pain", not phantom limb pain; pt is Left AKA
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    Still confused by Prolonged Services

    I code for Psychiatry and have struggled with this since January: Is it true that Prolonged Services codes (99354-55 Outpatient) can ONLY be used IF the PROVIDER DOCUMENTS COUNSELING AS THE MAJORITY OF THE ENCOUNTER ("greater than 50% of today's visit spent on counseling and/or coordination of...
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    Musculoskeletal Exam Elements

    I am confused on "Examination of the joints, bones, and muscles of one or more of the following six areas:" So, if the provider does an exam of each extremity (RU, LU, RL, LL) which may include 4 possible assessments, does each extremity count as a "bullet" and each assessment count as a...
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    Established Problem vs New Problem

    Pt being seen for the first time by new psychiatrist, who took over for doc who retired in Oct. I understand the NP vs Est Pt; this would be established patient to practice; However, when calculating Problem Points for MDM, are the patient's problems considered to be "Established problem (to...
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    99354 w/o counseling documentation?

    Scenario: 99214 that meets key component criteria, but provider spent 60 min total with the patient (typical time for 99214 published by CPT is 25 minutes), no counseling documented. Can I add on 99354 for the extra 35 minutes spent? Any input/opinion is greatly appreciated Thanks! :)
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    99354 Prolonged Services

    Scenario: 99214 that meets key component criteria, but provider spent 60 min total with the patient (typical time for 99214 published by CPT is 25 minutes), no counseling documented. Can I add on 99354 for the extra 35 minutes spent? Any input/opinion is greatly appreciated :)
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    AHA Coding Clinic access anyone?

    I am desperately searching for online access to AHA Coding Clinic for ICD 9 CM without paying upwards of $1200 for other things I do not need. I work in a non-profit Behavioral Health/Psych Community Clinic, where we do not use a majority of ICD 9 codes on a regular basis, usually only Chapter...
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    Axis III for a physically healthy Patient

    Hi, all...Have any of you figured out a code for a Psych/BH/MH patient that is otherwise healthy, you know, no physical medical conditions? We are trying to resolve this issue, in the past V71.09 was used, but that does not seem appropriate. My supervisor is telling us that DSM 799.9 is used...
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    99223 Billed by MD and NP on same DOS

    Being new to the field, not only of behavioral health, but coding in general, this is my burning question of the day, that I have not been able to find an answer to. MD and NP both billed out a 99223 same DOS, with overlapping times..can this be right? Thanks for any advice/opinions!
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    L1832 Bioskin Knee Brace

    The brace I ordered for my patient was too small, even though we measured and ordered by Bioskin's sizing instructions. Anyone know how to bill the patient/non-medicare insurance for the return shipping costs? P.S. Anyone ordering Bisokin knee or elbow braces be aware, they do run small!! This...
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    Intrathecal Pump Refill

    As a student coder, but full-time Medical Assistant in a Pain Management practice, I'm looking for some help with a real-life scenario I'm having trouble with, hoping someone has some experience with this and can answer my questions: 1) My doctor is going to refill a patient's IT pump as an...
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