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  1. C

    E&M, missing 1 element (Using 1997 DG's)

    I would interpret the guidelines the same way. They specify when you need 3 out of 7. So when they don't specify you only need so many, it means you need all.
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    Dm + hf

    DM + HF isn't really linked well, if the documentation literally used a + sign, I wouldn't consider that proper linkage. A few things to consider Clinicians should not document with arrows or symbols and if they do, we should never code from it. While heart failure and other heart diseases...
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    Coding Manager Needed

    Coding Manager The Coding Manager will be accountable for successfully managing the Medical Coding team, audit documentation and coding practices to ensure accuracy in the data provided to CMS. The Manager will provide coding expertise as well as administrative oversight to ensure successful...
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    External Cause Codes - comes in for injury

    It's more about correct coding than which insurance requires what codes. That being said, looking at the guidelines, they say "There is no national requirement for mandatory ICD-10-XM external cause code reporting." In the absence of a mandatory reporting, providers are encouraged to...
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    E&M coding with Fever

    I say 99202. MDM is low and while there's a lot of documentation, was it all truly necessary for this visit? Documentation volume should not be considered when assigning a code. There's a lot of family history data that's irrelevant. Also some of the HPI is the same as what is listed in ROS...
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    Wiki Aftercare code for an MI after 4 weeks

    If that's the physician's documentation, I would. He does have to state that it's healed or indicate if there's ongoing issues.
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    Wiki Aftercare code for an MI after 4 weeks

    I don't think I23.8 would be appropriate because that's for complications following an acute MI. the Coding Guidelines indicate encounters occurring while the MI is equal to, or less tham, four weeks old, including tramsfers to another acute setting or a postacute seeting, and the patient...
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    Wiki Excludes 1 & 2 note question

    Was the broken/fracture around the internal prosthetic joint (which is T84.040-) or broken internal hip/knee prosthesis. That's the key to me in looking at this. How is it described. Around the internal joint or actual broken prosthesis. And I think that's why Excludes1 is on the T84.01-...
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    stenosis help

    In I10 they don't reference it as recess stenosis and no longer have the stenosis with neurogenic claudication code (724.03 in I9). If you use the AAPC crosswalk tool, 724.03 goes to M48.06. Spinal stenosis goes to category M48, under this indicates caudal stenosis. In I10 if the cause of the...
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    smoking status non smoker

    The Coding Guidelines has instructions on this. Look there, it also mentions category Z77. Category Z77, other contact with and (suspected) exposures hazardous to health, indicates contact with and suspected exposure. Then also look at the specific chapter guidelines too.
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    Anesthesia webinars???

    webinar https://www.aapc.com/ResetPassword.aspx?id=7hCgR4Q1z1c=&exp=OWetPyqajmzSJFGWZQQOV9S28NODOcNf&enc=true Here's a link to an older webinar AAPC had and it's only $40. Decision Health is great, they have a forum that's free. But their training is pretty expensive. The ASA codes haven't...
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    D vs. S for mechanical joint failure

    Patient admitted due to failure of total hip. Underwent revision. For the T84.090- code, would the correct 7th character be an S. The failure is a sequela of the original implant or would it be D for subsequent encounter since patient had surgery and is now being followed by rehab? I'm...
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    Can you use Past Medical History for ROS

    I would only use them if the ROS notes something about patient's diabetes (BS log, numbness or lack of in feet, etc). same with HTN, does patient have any complaints. Otherwise, it's just PMH
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    Pain management Please help with coding

    Reviewed The AMA CPT Reference of Clinical Examples against your report and it looks to me like it's a sacroiliac joint. See CPT 27096
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    History of Coding

    The coding guidelines indicate once the cancer is surgically eradicated and no further treatment is being directed at the malignancy whether it's chemo, radiation or medications such as Tamoxifen, Femara, etc...we are to code as personal history. If the physician's notes do not indicate any...
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    ICD-10 question-Infectious Disease

    I agree with Amber. I would not code T50.3X1A as what you posted makes no mention of water being the source. Additionally, as you said, it is pretty cut and dry and there are no further instructions listed to code also or use additional codes for Legionnaire's. Reason I would not code it...
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    hand written corrections

    CMS guidelines indicate the error has to be lined-out, dated, initialed. The correct information should then be written and initialed and if needed direction to revised information should be indicated. This link has some additional information...
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    Echocardiogram and risk table

    Hi, I know that reviewing/ordering tests falls into the reviewed data category. My question is, would an echocardiogram ever be considered cardiovascular imaging studies with contrast and no identified risk under the diagnostic procedure(s) ordered moderate risk table? Physician did an EKG in...
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    Experienced anesthesia/pain coder needed

    Experienced anesthesia/pain coder needed. This is not a remote position. the client is in Santa Ana, CA. You will need to pick up and drop off work. It is part time coding both anesthesia and pain. email resume to: chris@pmplusinc.com
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    Scoring Physicians

    Hi all, Does anyone have a template or methodology they are willing to share for scoring physicians during an E&M audit? I've got a few samples, but want a tried and proven method to use. Thanks in advance to all who respond. Kristin
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    In need of experienced E&M Auditors

    Hi all, We are in need of experienced E&M auditors. Please email me privately through the forum with your resume/contact information so I can forward the test and more information. This is a remote position and can be FT or PT. it is a contract position currently and not permanent...
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    Need experienced E&M Auditor

    Hi all We are looking for experienced E&M auditors. Please send me a private message with your resume/contact information. This is remote work and can be PT or FT. It is contract/project work not permanent at this time. You can email me through the AAPC site or at...
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    64483 and 64484 - If the doctor injects at the L5/S1

    L5S1 is considered one level of the spine.
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    Risk Level

    Hi all, when assigning risk level for a patient who is counseled on receiving an epidural injection in the future and all risks associated with it are reviewed...do you assign this as a High risk level? I see discography under high as well as elective major surgery, but an epidural isn't...
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    E/M Coding Software/Encoder

    Hi Do any of you use E&M coding software or an encoder? If so, which one? I'm looking for options or alternatives to Intellicode and 3M. Thanks in advance:D
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    R/o spontaneous rupture of membrane

    Physician's cannot code for rule out conditions. Suggest you query the physician for the final confirmed diagnosis.
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    Looking at Anaheim...

    There are a lot of hotels within walking distance and most will offer shuttle services to/from Disneyland itself. Use something like expedia.com, booking.com, tripadvisor, etc and search. I'm so lucky I live within 30 minutes of Disneyland so I'll be able to commute each day!
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    H&Ps

    :D Hi all, I have an anesthesiologist who wants to perform pre-operative H&Ps in a hospital clinic. He will have NO involvement in the anesthesia services and will be performing the H&P only. Questions--can/should this be done? It is unbundling services (to an extent) so I want to be sure of...
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    AnesthesiologiIst performing H&Ps

    Thanks Michelle for the reply. This anesthesiologist will have nothing to do with the actual anesthesia services. Realizing it's bundled, my quest is to find out if others are seeing similar situations and are able to successfully get paid. The patient must have an H&P by a provider prior to...
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    AnesthesiologiIst performing H&Ps

    Hi all, I have an anesthesiologist who wants to perform pre-operative H&Ps in a hospital clinic. He will have NO involvement in the anesthesia services and will be performing the H&P only. Questions--can/should this be done? It is unbundling services (to an extent) so I want to be sure of...
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    AnesthesiologiIst performing H&Ps

    Hi all, I have an anesthesiologist who wants to perform pre-operative H&Ps in a hospital clinic. He will have NO involvement in the anesthesia services and will be performing the H&P only. Questions--can/should this be done? It is unbundling services (to an extent) so I want to be sure of...
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    Coding Hypertensive Heart and Chronic Kidney Disease

    You are correct. Site the Coding Guidelines. The Official Guidelines state assign codes from combination category 404, hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. There MUST be a causal...
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    Femoral and Sciatic blocks

    Question-- Physicians are documenting femoral and sciatic blocks. Sometimes femoral and popliteal blocks done at the same time. Is it appropriate to bill for both a femoral and sciatic block at the same time? Is there guidance to refer to either way? Thanks in advance. ps--I also posted...
  34. C

    Femoral and Sciatic blocks

    Question-- Physicians are documenting femoral and sciatic blocks. Sometimes femoral and popliteal blocks done at the same time. Is it appropriate to bill for both a femoral and sciatic block at the same time? Is there guidance to refer to either way? Thanks in advance.
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    ASC Coding/Billing

    :eek: Hi, It's been over 10 years since I've done ASC coding/billing so I need some help.... 1. Code CPTs and ICD-9 2. Don't code medications as they are included, correct? 3. Do we submit revenue code for those medications? Or generic pharmacy? 4. If case was a pain procedure, do we...
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    Retrobulbar blocks

    For cataract and other eye cases, the doc is indicating a MAC as well as retrobulbar block. After doing some checking, it appears to me the block is a combined anesthesia and postoperative pain technique. My question is...is it separately billable? If so, what code would be used? And would...
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    414.00 vs 414.01- can you elaborate

    The Coding Clinic First Quarter 2004 page 24 posted guidance and clarification on coding for CAD in a patient who is status post CABG. Coding Clinic Fourther Quarter 2003, page 106 advised using 414.01 for a patient with a history of CAD post CABG; however 414.00 is the appropriate code. Coding...
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    Ultrasound Guided Transforaminal Injection

    Is anyone billing Medicare (California or other states) for an ultrasound guided transforaminal injection. We have Category III Code 0228T for a cervical injection. I'm looking for payment and policy information. Thanks in advance.:o
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    HCC Coding Changes

    Hi, I've been hearing that there are big changes coming for HCC coding. I've read through most...but the one 'rumor' I'm hearing and trying to confirm, I haven't been able too so I need help: What I'm hearing is that CMS is going to start focusing on those HCCs submitted only once by a...
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    need help with 2 procedures...urgent

    Thank you for the information/responses!
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    need help with 2 procedures...urgent

    :confused: Physician performed a chondrocostal injection and an injection of the thoracic nerve at the scapula. The area over T5-T8 was prepped with Betadine and a 25-gauge needle placed in the chondrocostal joint at T5-6 and T6-7 under fluoroscopic guidance. 2cc of 0.5% marcaine with...
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    Ca work comp experts...help!!

    I need help with how CA workman comp wants us to bill injectable medications. For example 150mg of Demerol. Do we use the HCPCS or something else? I have a doctor that is questioning how I am billing them. I need help ASAP!
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    Ca work comp experts...help!

    I need help with how CA workman comp wants us to bill injectable medications. For example 150mg of Demerol. Do we use the HCPCS or something else? I have a doctor that is questioning how I am billing them. I need help ASAP!
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    labs and venipuncture

    Labs are not my area of expertise, so I need help with this: office bills 36415 rather than labs, is this appropriate??? Office bills 36415 and lab codes (i.e. 80050, 80061, etc); is this appropriate? Thanks
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    Lab and venipuncture

    I have a provider billing 36415 with routine labs (ie lipid panels). Is it appropriate to report 36415 when drawing blood for labs? It seems like it would not be...but lab billing/coding is not my area of expertise. I didn't see anything on the CCI to say it was bundled. It just seems like...
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    Sending coders to work remotely

    I've worked remotely before and it's great. There are a lot of benefits for both employee and employer. To track the employee is working their hours, do you require the employee is still working an 8-5 type shift or are they allowed to complete their 8 hours any way they like over the day...
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    Dealing with a Provider who questions your ability?

    At some point or another I think we all deal with someone like this. I've found that explaining the coding guidelines and my role as a coder and auditor helps. If they understand that we cannot assume anything about what they've written and that we are not clinicians they understand that...
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    URGENT...need help with CPT for open placement of subarachnoid shunt

    Thanks for the help! I waivered back and forth on the codes....and agree that perhaps in this procedure 63740 is not appropriate but wasn't sure as I don't see this type of case often.
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    CEMC optional reference

    I have the same type of binder..with the DG guidelines, the audit tool. But I'm not sure what, if any, other optional reference to take with me. Maybe the study guide??? Or an E&M Coding book??? Then again having to flip through to many references will just take too long. So I'm not sure...
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