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    HELP! Can the Diagnosis be documented anywhere in the note or only the MDM?

    Good morning, I've always been instructed (for over 12 years) that the diagnosis MUST be documented in the MDM portion of a chart note. Even the guidelines cover this in that section and don't address it in other sections of the E/M. However I have a few Vascular providers pushing back that...
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    Documentation requirements for 'reviewing' EKG's, etc.

    Good morning members. I am searching for information on what must be documented to prove a provider 'reviewed' an EKG, lab, X-ray etc. My company is trying to establish guidelines for our providers and I'm struggling to find a 'guideline' on what should be documented to support this. We have...
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    Cpc, cemc surgical coder-gen surg, ortho, etc

    Hi my name is Kelsey and I am putting my resume out there to see what options I may have for a remote position. I currently reside in Woodburn, OR and work remotely for a hospital in Longview, WA. Specialties that I am familiar with are General, Breast, Thoracic, Colorectal, Vascular, and...
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    Cpc, cemc-multiple specialty experience

    I currently reside in Woodburn, OR and work remotely for a hospital in Longview, WA. I am looking for a remote position but willing to come into the office occasionally if office/hospital is within 45 minutes to 60 minutes one way. Specialties that I am familiar with are General, Breast...
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    Laminectomy T9, T10, T11 Help!

    A co-worker and I are in debate as to what is correct for the OP note below. Here is option 1: 63266, 22610, 22614 and 20936 option 2: 63016, 22610, 22614, 20936 Any suggestions or advice is greatly appreciated. Thank you Kelsey, CPC PREOPERATIVE DIAGNOSES: 1. Epidural abscess at T10...
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    Hip Spacer Exchange help!

    I need help with a hip spacer replacement. Would I bill the hip revision or woud I bill the spacer replacement. Please see below. Thanks. PREOPERATIVE DIAGNOSIS(ES): Periprosthetic infection, right hip; right total hip arthroplasty. POSTOPERATIVE DIAGNOSIS(ES): Periprosthetic...
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    Cemc exam

    Anyone taken this in 2011 with the new OBS codes and new J codes that came out? Words of advice for me? I took this a couple months ago and failed my first time. I did not pass the J code section and there is only 1 on the exam. I spoke with AAPC about this since I work surgery and KNOW my...
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    Define "counseling" for 90460 ???

    Hi my fellow coders and I would like some insight on the CPT 90460. We understand how to use this correctly but are unsure what constitutes as "counseling". What must be documented in the chart? Does the doctor have to specify that it is "counseling" or can they use smart phrases?? Any help...
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