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    93010 What day of service do you use?

    For 93010, it is the date of the interpretation which oftentimes is different than date of recording.
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    Wiki Help with Sepsis Proteus Mirabilis Due To UTI

    Nobody is probably paying attention to this thread at this late date, but I am going to write, anyway. Yes, there is a "Code First" note at A41; HOWEVER, read through those conditions. That is a very select group of patients who will use one of those diagnoses: T81.4 Postprocedural sepsis...
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    Post tonsillectomy hemorrhage

    I am having difficulty finding the appropriate ICD-10 code for post tonsillectomy hemorrhage. Thank you!
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    It appears that without any further qualifiers, I am unable to code PMH of "lupus." I do ER coding, and I am finding "lupus" quite frequently in the PMH, but without a qualifier, I'm not sure how to code it. This is what my encoder says: * Anticoagulant * Discoid (local) * Erythematosus...
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    G6PD deficiency?

    I found this thread with ICD-9 codes: When coding out G6PD deficiency starting with "deficiency" and then glucose-6-phosphatase, it takes me to either glucose-6-phosphatase deficiency (von Gierke disease) or glucose-6-phosphate...
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    Weeks of gestation with spontaneous miscarriage?

    Is it required to code weeks of gestation when there is a documented spontaneous miscarriage? If not known, code unknown weeks?? Thank you!
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    Weeks of gestation

    I'm hoping someone might be able to shed some light. I've spent quite a bit of time researching this, and it is so early in the ICD-10 process, I really am not finding anything. I've been instructed by a lead coder to NOT code the weeks of gestation if it is stated as "estimated,"...
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    Postpartum condition versus complication?

    Coding guidelines state that ANY condition being treated during pregnancy is to be defaulted to a pregnancy complication, i.e., It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy. As regards postpartum conditions, the guidelines state...
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    Obstetric codding in icd 10

    I found this on an OB "cheat sheet" in AAPC: Patient with monochorionic twin gestations presents with ultrasound indicating polyhydramnios of twin A (fetus 1). She is 30 weeks gestastion. O40.3XX1 Polyhydramnios, third trimester, fetus 1 Z3A.30 30 weeks gestation of pregnancy Here is the link...
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    Periprosthetic fracture AND prosthesis dislocation

    My diagnosis is posterior hip dislocation with periprosthetic greater trochanter fracture. I have a code for a periprosthetic fracture of the hip, right, initial, (T84.020A) and a code for prosthesis dislocation of the hip, right, initial (T84.040A). Do I use both, or is there a better code...
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    AAPC's Online Course for ICD10...A Question

    I completed the AAPC ICD-10 proficiency course in September 2014 and entered the appropriate information into my CEU tracker. However, when I click on my account now, it shows the ICD-10 proficiency course as "incomplete." :confused: Is there some place else that I can check on my profile to...
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    Wiki "Infected laceration repair"

    Patient presents to ED with knee pain and swelling, S/P laceration repair 3 days ago. Clinical Impression is "infected laceration repair, right knee." From what I'm reading (granted, it is an ICD-9 Coding Clinic), the coder "should assume that the wound is the problem and the source of the...
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    Detailed (?) extremity exam with 1995 guidelines

    Thank you so much for your help!!
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    Detailed (?) extremity exam with 1995 guidelines

    There isn't a lot of information out there about this, at least that I can find. Here is my exam, and I'm trying to figure out if this justifies a "detailed" extremity exam. VS: (documented but not reiterated here). GENERAL: (documented but not reiterated here). RESP: (documented but not...
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    Detailed (?) extremity exam with 1995 guidelines

    There isn't a lot of information out there about this, at least that I can find. Here is my exam, and I'm trying to figure out if this justifies a "detailed" extremity exam. VS: (documented but not reiterated here). GENERAL: (documented but not reiterated here). RESP: (documented but not...
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    Path report: Basaloid neoplasm

    That is not a code I assigned to it; this is the code the referring MD sent with the specimen, outside my control and not an MD I can approach for clarification, though I do understand what you are saying. Thank you for your help.
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    Path report: Basaloid neoplasm

    I am coding for facility only so only have the path available. Diagnosis according to the path report is "basaloid neoplasm." I have no idea as to an ICD-9 code here. Pre-path diagnosis is 238.2, neoplasm of uncertain behavior. Do I have to default to this code as post, also? Thank you!
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    Dual coding - Current TIA with CVA residuals

    Thank you so much for your help! I may just have to do that.
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    Dual coding - Current TIA with CVA residuals

    We are dual coding ER charts right now, and my patient has a current TIA with residuals from a prior CVA of generalized weakness and dysarthria. I attempted to code these conditions through my Encoder and then through my Coding Book but got an Excludes1 note that I can't use these codes...
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    Disk bulge and facet hypertrophy

    I have an MRI with report stating: L5-S1: Mild posterior bulge is present without canal narrowing. Mild foraminal narrowing is noted on the right related to bulge and facet degenerative change present. On the left, similar mild narrowing is noted related to mild bulge and facet hypetrophic...
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    ROS "all systems negative except as marked"

    On the E&M worksheet, we can count a complete ROS *if* there is at least one system reviewed plus the statement "all systems negative except as marked".....and we know we can pull ROS elements from the HPI if not already accounted for. However, if the only ROS element I have is in the HPI *and*...
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    History of MRSA and MRSA carrier?

    Can someone explain to me the difference between "history of MRSA" (V12.04) and "carrier or suspected carrier of MRSA" (V02.54). Thank you!
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    Wiki Dementia and Parkinson disease - ICD-10 Code for Parkinsons disease

    My patient has "dementia" and "Parkinson disease" with no cause-and-effect relationship implicitly stated by MD. In coding these, my Encoder takes me to an option on Parkinson disease of: 1) With dementia 2) Parkinson disease alone Because the guidelines state that "with" actually means "due...
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    Components of extremity PE

    I am not able at this time to post the remainder of the note, and I apologize for that. I know that limits the feedback I can receive. As far as "pain not being mentioned," I'm confused by this. I'm not sure where in the thread this is mentioned? I'm also confused as to "not aware of any...
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    Components of extremity PE

    I agree. I may not have stated it correctly, but I am not trying to push it to a level 4. I don't believe the neuro, vascular, and skin should count as separate entities. I was attempting to find justification somewhere else that supports my opinion. Coming in as the "new guy" and questioning...
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    Components of extremity PE

    I *really* prefer the cases where the E&M level has been determined without the use of the PE, especially when there is such a gray area like this, but sometimes this is actually the deciding factor in the overall E& you all know. This one did come down to the PE part of the equation...
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    Components of extremity PE

    This was my thought, actually maybe even problem focused because he only did constitutional (VS) plus the extremity exam which would be 1 BA/OS plus 1 OS which doesn't even equal EPF (1 BA/OS plus 2-7 OS). I was having difficulty expressing that in words to my co-workers to even open up a...
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    Components of extremity PE

    Laura: Thanks for your reply. In counting five OS, you're counting Constitutional, MSK, Neuro, Vascular, and Skin? Just want to make sure I'm understanding correctly. I do value everyone's opinion, especially when it comes to E&M because everyone interprets things so differently.
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    Components of extremity PE

    So you're not counting the neuro, vascular, and skin as three additional OS, just inclusive in the extremity exam?
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    Components of extremity PE

    I have a physician who will document vital signs (constitutional) and then an extremity exam but absolutely nothing else, as follows: There is a puncture wound in the plantar heel, surrounding soft tissue swelling, but no erythema, drainage, or purulence. Ankle is normal to inspection...
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    Oncocytic cyst

    I am stumped on this one. All I have is a path report, no access to the operative report. Preprocedure diagnosis from performing MD is "gingivolabial sulcus neoplasm," and the path came back with "oncocytic cyst with abscess, negative for carcinoma." I am not finding anything on the oncocytic...
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    Additional references for coding acute on chronic pain

    I'm going to add/change something in my prior examples, just for additional scenarios: 1) Patient #1 presents to the ER with "LS strain from repetitive movements in gardening." However, this patient also has a diagnosis of chronic LS back pain. Because the word "acute" did not appear in the...
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    Additional references for coding acute on chronic pain

    Thank you both for your help. In other words, the only time I would code the chronic back pain (338 series) is: 1) If it is a secondary diagnosis, i.e., patient presenting with something else but has chronic pain in his PMH but is on maintenance meds FOR that pain (Lidoderm patch, methadone...
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    Additional references for coding acute on chronic pain

    I am looking for additional references on coding acute on chronic pain. I have read everything I can possibly find, Advance articles, many threads here, but I am just not grasping it. Just when I think that I have it down, I have another coder in my department look at my codes, and they are...
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    CC: Family requests workup of multiple falls

    I'm really struggling with the coding of this case. Family requests workup of the cause of patient's recent frequent falls. Patient also has multiple abrasions as a result of the recent falls. I really can't give you much more info other than the above because there really ISN'T much more than...
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    OB ultrasound - V28.81 versus V28.3 (see HBM April 2015)

    In the new Healthcare Business Monthly, there is an article on OB ultrasounds 76805 and 76811. I am a little confused regarding the diagnosis codes V28.3 and V28.81. We have been utilizing V28.81 when patients present for an antenatal ultrasound for dates and anatomy. Our physicians order...
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    Use of social history in E/M determination

    Are you able to count "social history" as an element of your HPI determination if there is a discrepancy in that information? Example: It is documented in one location as "ex-smoker" (or "former smoker" or similar) but in another location as "smokes cigarettes daily." I'm thinking you cannot...
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    ISO: Medical Necessity resources

    I'm not sure where this would go, so I'm defaulting to this forum. I'm looking for resources on Medical Necessity as it pertains to E/M in particular. I'm looking for web sites, forums, webinars, etc., pretty much anything. I've tried a search in the webinar archives here at AAPC and crashed...
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    E&M and urinalysis codes

    Are you sure that is the reason for the denial? We are paid for 81000 urinalysis (the only one we do in-office) and E/M codes. We are starting to notice Medicare denials for 81000 and E/M but for the reason of "no medical necessity." This is especially true in the case of prostate CA or...
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    History of polyps, screening colonoscopy

    Here is a pretty helpful link on colorectal CA screen from CMS:
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    Remote companies and internet access

    I have a job offer from a company that is contigent on me finding a different internet provider. We live on a mountain and have ONE choice for internet and that is satellite which is the one form of internet that can't be used with this particular company. Do any of you know if any remote...
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    Requesting some feedback re: Remote Coding

    Random question if any of you care to weigh in: There are several here who have worked for several different remote companies. I have a job offer from a company but only if I can come up with a different internet provider--we live on a mountain and have ONE choice for internet and that is...
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    "Dropping off specimen" for culture

    Thank you for your help. As always, you are a wealth of info.
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    "Dropping off specimen" for culture

    Our office has the capability to run a UA, but we do not have the facilities to run a culture. Therefore, it has to go to an outside lab for culture. Some of our chronic UTI patients will come to the office for the sole purpose of leaving a specimen for culture. We collect it for them, i.e...
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    NCCI Edit versus AUA Bulletin

    Thank you for all of your help!
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    NCCI Edit versus AUA Bulletin

    I have conflicting info here. I have a Coding Brief from the American Urological Association, stating that CPT 52353 (cysto with ureteroscopy and/or pyeloscopy with litho) and 52332 (cysto with stent placement) have been combined to one CPT code of 52356 (cysto with ureteroscopy and/or...
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    Bladder CA 188.9 versus hx of bladder CA V10.51

    Thank you for your response. That is what I thought. You are always most helpful, and I do appreciate you :)
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    Bladder CA 188.9 versus hx of bladder CA V10.51

    I have a question regarding the use of 188.9 versus V10.51. We see bladder CA patients routinely for surveillance cystoscopy, sometimes every 3 months for several years and then yearly, etc. ICD-9 says that once the previous malignancy has been excised and there is no evidence of existing...
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    Aspiration in global of hydrocelectomy

    Can I bill for aspiration in the global period of a hydrocelectomy? Using a Toshiba unit, scrotum was scanned. Left testicle unremarkable, but there is a moderate-sized fluid collection inferior to the testicle. A spot on the scrotum was anesthetized, and 10 mL of fluid was aspirated without...
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    CEMC exam

    I've seen many different E/M auditing tools. Is there one that is better than the next to use for the test? Thanks for your help!