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    Clinic E/M

    I have a really nice laminated emergency room E/M table (chart) from CMS. On the top it says "CMS DOCUMENTATION REQUIREMENTS SUMMARY." It helps decide what E/M level to use by going down the table. Do any of you know if there's one for OP or clinic E/M? Thank you!
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    I am the supervisor of Health Information Management in a rural hospital, and I am looking for a new Quality Assurance project. Our old QA project is ending and I need inspiration and fresh ideas. What do you do?
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    We are a rural Critical Access hospital, and we provide telespsych services through a psychiatrist in nearby city. The only part we play in the patient's visit is to rent the space for the service and set up the monitor for the psychiatrist. Other than that, we do not have access to the...
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    Emergency Room Birth

    We do not normally deliver babies at our Critical Access Hospital, so this is not my forte. We recently had a woman deliver at 35-weeks in our emergency room. The baby was immediately transferred, by life flight, to larger hospital. My problem is coding the baby's part of the ER. Someone here...
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    ED Consult

    A patient presents to the ED with a dog bite to the face. Our hospitalist called another physician (who is also a surgeon) to the ED to repair the wound. The patient is Medicaid and the bill has been denied. The patient was discharged to home (no admit). I billed 99283 for the hospitalist with...
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    Modifier Books

    Can any of you recommend a good modifier book? I code for a small CAH hospital and we see a little bit of everything. I would like to find a go-to book that explains all CPT modifiers. Any suggestions? Thanks, Verna
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    Our CAH hospital is currently using NextGen (Harris bought them recently) and have to find another EMR within the year. AthenaHealth was here last week showing us what their system could do. Have any of you worked with the Athena EMR hospital version? Thanks, Verna
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    Signature Verification

    I work in a critical access hospital and have a question about our Signature Verification Log. We often have to hire traveling RN's to staff our hospital. They are usually only here one shift. Are they required to sign our Signature Verification Log or are they covered because we hire them from...
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    Proficiency Test

    I read somewhere that you should not use Internet Explorer to take the test. That's all I have at work, so I'm a bit concerned. Have any of you used Explorer when you took the test?
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    IP surgery questions

    Hello wonderful people. I have questions regarding IP surgery and ICD-9 procedure coding. I've always been an OP coder, but now I am coding for our new surgeon. I'm trying to stuggle through this one, but it's very daunting. We had a patient who had the following: 1. Attempted subclavian...
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    Hospital Clinic Visit

    Our hospital has recently opened an oupatient clinic staffed by a general surgeon and an ENT surgeon. My question is this: when a patient comes in for a pre-produral visit for a screening colonoscopy, and has no complaints, what ICD-9 code do you use? Does the V70.0 code usually get paid, or is...
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    Our hospital has a new surgeon, an ENT. I've never coded for an ENT before, so I'm hoping some of you can guide me. Our doctor recently performed surgery on a 14 year old (general anesthesia) and writes: Left myringotomy and tube insertion; right myringotomy with no tube insertion. I'm just not...
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    Revenue Code

    We have a new ENT provider that has been doing procedures in his office. I'm a hospital coder, but have been given the task of coding these procedures. My question is about revenue codes. What revenue code should I use for scopes and simple procedures done in a clinic office? Can you tell me...
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    Patient presents to the ED with SOB. Chest tube was put in to drain a large hemothorax of the chest. Patient expires and Dr. writes "Cardiac collapse based on exsanguination." I've been going back and forth with my ICD-9 codes. Any suggestions?
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    Medicare Sleep Studies

    Our hospital performs sleep studies (95810) once or twice a month. Often patients come in with symptoms such as snoring, headaches, obesity, GERD, etc. The provider orders a sleep study and I code off of the report when it comes back. We're finding that Medicare will deny payment if the findings...