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

    Thank you for your reply. So if this is the case then each section/components of the E/M level does not need to stand on its own? Wouldn't that sort of be double dipping to make each section 'complete'? Do you have something written that it would be OK to allow this? My place of employment...
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    Auditor states drug ordered as IV over 2 minutes must have a doc stop time?

    When its just an IV PUSH there does not need to be a stop time. If it truly was an IV drug hung for say 20 minutes yes there would need to be start and stop times but the PUSH IV drugs do not need the stop time. Here's a snipped from the encoder we use. Physician or other qualified...
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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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    family history

    I would not use the family history codes unless the provider documents them 'somewhere' in the current note. Somewhere meaning anywhere in the current note. Each document stands alone, UNLESS the provider wants to refer to his initial note with the date and where it can be located, then you...
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    systems vs areas

    Yes I would count this under the respiratory organ system. Kelsey, CPC, CEMC
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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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    Modifier 76,78,79????

    Where was this procedure performed? Generally if they are in the office we would use -58(related) but if taken to the O.R. -78(unplanned return to O.R.). The -76 is for repeat procedure on the same day. Hope this helps. Kelsey, CPC, CEMC
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    Use of Mod 58

    I would bill -78. Generally billing -58 indicates that this was a 'planned' return to the O.R. and I am assuming this was not. 58-Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure...
  10. P

    dislocation total shoulder

    I would agree with the 23655. That is what we use. :) Kelsey, CPC, CEMC
  11. P

    spacer exchange Total Knee

    We bill 27486-52 here in Washington. I have searched high and low and our COSC coder stated to use the above :) Hope that helps. Kelsey, CPC, CEMC
  12. P

    need help with observation H&P

    I work these type of scenarios everyday. Below is my opinion. 1. Can I use the office note for H&P for the observation service if the doctor doesn't refer to it in his documentation for the visit in hospital? The provider can 'refer' to a previous note with date and who's note in the past...
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    help with elements

    Note reads: patient presents with rash(chief complaint), swelling(associated signs), redness(quality), warmth in right arm(location). The patient has a fever(constitutional ROS), no N & V(GI ROS), is SOB(respiratory ROS), has had a blood clot in leg while pt was in ICU, has a hx of breast...
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    e&m cardiology audit

    I would give credit for 2 data points with this. I see this all the time with my cardio providers. Kelsey, CPC, CEMC
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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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    Coders posting payments

    I have never heard of that! I worked in a private practice and we posted payments all the time as a coder/billing specialist anything to do with the business office we did it. Now I work for a hospital but still have never heard of this. Kelsey, CPC, CEMC
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    What modifier for 33244?

    I know some insurance company's automatically reduce the 2nd procedure but others will not. I would bill 33244-51. I add it regardless just to be safe when I am working any surgical procedures. Other than that I am not sure what other modifier they would want. Kelsey, CPC, CEMC
  18. P

    99213 vs 99214

    I would agree with 99213 as well. Kelsey, CPC, CEMC
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    Level ?

    I agree with LLovett. Level three. As a coder you have to be willing to pull information for any section from anywhere in the document just as long as you are NOT double dipping! Kelsey, CPC, CEMC
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    level of history

    I do not see any HPI elements. I also do not see a chief complaint which is a requirement to bill an e/m regardless what other elements you may or may not have. I would say unless the provider wants to addend this note I would not bill it. I'd give the provider the chance to but after a week...
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    Wiki Cpt 99231,99232, 99233

    These are used when the physician see's patients on an inpatient basis(follow up visits). To bill a 99231 you need 2 of the 3 components: Problem Focused History, Problem Focused Exam or Straight Forward or Low MDM, or based on time 15 minutes, 99232 you need again 2 of the 3 components...
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    Help with HPI and ROS

    I found this to have a Comprehensive HPI, and Det ROS. Hope this helps give you an idea :) Kelsey, CPC, CEMC HPI Here to (Chief complaint)-f/u numerous abnormal labs from last week. Not seen by MD in over 15 yrs. Has been feeling fatigued(associated signs/symptoms). Has had 10 lb weight...
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    Consults

    As long as all the requirements are met to bill a consult, it should not be a problem. I have a general surgery group that does this, as well as an ortho group. They all have sub specialties and refer to each other. We have the same tax ID but they do have separate NPI #'s for say breast...
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    1997 guidelines- musculoskeletal elements

    I responded to the other post as well but here are my thoughts: I find 6 bullet points out of the musculoskeletal section of the 1997 general multi-system exam. The provider indicates hands, wrists, elbows, shoulders, spine, hips, knees, ankles in pleural which indicates to me he examined both...
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    musculoskeletal portion of multisystem exam

    I find 6 bullet points out of the musculoskeletal section of the 1997 general multi-system exam. The provider indicates hands, wrists, elbows, shoulders, spine, hips, knees, ankles in pleural which indicates to me he examined both sides of the body. So in turn that equals 1 bullet point for...
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    "all others negative" variation

    We would give credit where I work. However we do encourage the providers to use the 'all others negative". Less liability if they use the shortcut. :) Kelsey, CPC, CEMC
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    HPI help

    This sounds more like MDM than it does HPI. I do not see any HPI elements. Kelsey, CPC, CEMC
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    Orthopaedic speciality exam

    A co worker of mine took this and she said there are alot of spine questions. Def study up on that! I plan to take this by the end of the year and agree that the practice exams seem pretty basic. Good luck! Kelsey, CPC
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    need suggestions quickly please

    I would look at 11750 for the nail removal. I would agree with your area for the cyst removal as long as the size is documented in the report. Hope that helps. 11750-Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal Kelsey, CPC
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    necrotizing fascitis

    I do not believe there is a specific code yet for other areas of the body. We default back to the 11044 area. Kelsey, CPC
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    New vs. Established

    Where I work something similar happens. We have a colorectal surgeon and he often times does colonoscopies on patients(w/o seeing them first) then will see them in follow up in the office. We are allowed to bill an est pt code due to he seeing them face to face. It may be your work place...
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    surgical dressing/non surgical dressing

    Is the wound from the surgery? If so then I would be billing the V58.31. The V58.30 would be for other reasons such as an abscess, wound from a bite or other things like that. Hope that helps. Kelsey, CPC
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    Dx code help-Can anyone help

    I would be inclined to look at 202.1x. If EBV stands for Epstein-Barr virus, I'm not sure you can get more specific then the 202.1x area. Hope that helps. Kelsey, CPC
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    Ortho Billing E/M in ER

    Bill the ED codes if they do not accept the consults. We have been doing this for years w/o problem :) I don't have documentation to prove its the right route but works for us here in Washington state. Kelsey, CPC
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    procedure in office

    I would look at 26040 and 26045. You are still billing the providers fee even though its in the office. May edit for wrong place of service but it that's what he truly did then he should get to bill for it. Personally I think there needs to be more documented but that is just me being picky...
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    Cellulitis

    Couple of questions, is the provider doing these or the nurse? Are they documenting that they 'debrided' or just cleaned? How deep are they going? If it is just skin then I would say you are coding it correctly. If they go any deeper then you would need to look at the 11042 area of codes. I...
  37. P

    1995 exam

    Yes you can mix them but to get a comprehensive on the exam they must ALL be from the organ systems area. So in this case I would give the provider Det for the exam. I would look at the CMS 1995 guidelines. It should help you define the requirements. Hope that helps. Kelsey, CPC
  38. P

    Visit For Sentinal Lymph Node Study Only

    Generally when we do this we are checking to make sure the cancer has not spread to the lymph nodes and would bill the 174.X. Hope that helps. Kelsey, CPC
  39. P

    Modifier 58

    Have you looked at -79(Unrelated Procedure or Service by the Same Physician During the Postoperative Period)? I have a general surgery clinic that has multiple sub specialties within it and I have this problem all the time. Kelsey, CPC
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    Excisions, Repairs, and "separately reported"

    You only need the -51 on the 12051. This is not bundled into the 11640 so no need to add the -59 to unbundle it. Hope that helps :) Kelsey, CPC
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    ER Consult

    We bill ER codes and we follow CMS. We convert to the New/Est is when the patient is in OBS status. Hope the helps :) Kelsey, CPC
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    62311 billed with 64635

    My instinct says this is probably going to be denied BUT I would agree with you in adding the -59. They are different locations so the provider should not be marked down or not given credit for his/her work. Good luck with this one :) Kelsey, CPC
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    Pain Management RFA

    If you want to give me your email address or message me on here I would be happy to get you some information tomorrow and an op note that is compliant. My doc does these all the time and he is AWESOME at documentation. It is true they are billed per facet joint beginning this year which is...
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    E/M Level - A patient came in with a history of breast cancer

    Oh boy is this one tough. My docs have documented little before on some procedures but this one seems a little too light on the documentation. From a compliance standpoint would he/she feel comfortable in an audit with Medicare? Eeeks. As for the level. I don't see any HPI elements to bill...
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    Can more than 1 MD charge for D/C?(99238)

    I guess it depends on the facility. I know many different specialties see pts in our hospital but we only allow one d/c regardless who is the attending. :) Kelsey, CPC
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    Fracture and Dislocation

    I would. At the time of the initial visit you had not idea the patient would need to be brought to the O.R. for the shoulder dislocation. Just use appropriate modifiers on the shoulder dislocation. Kelsey, CPC
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    Foot Amputation then BKA

    12/12/11 I would code 27882-Amputation, leg, through tibia and fibula; open, circular (guillotine) and for 12/16/11 I would code 27880-Amputation, leg, through tibia and fibula. You stated the 12/16/11 was staged so I am assuming the provider made notation that they would need to further...
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    Fracture Care Issues

    First scenario I would agree fracture care is billable. Provider is following the fracture through its healing process and requesting the patient come back and do x-rays to see the progress. Second scenario do they state anything about doing x-rays? We would bill fracture care since the...
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    Billing for H & P

    Did the PA order any testing to be done following that appointment? If they are not doing any additional workup I don't believe he/she could bill for it. I know we have many that come back for their pre-op type visit but its always included in the global period because the decision for surgery...
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    CPT code for suture of gastrotomy

    I would agree with your code choice. Kelsey, CPC
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