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    Date of Service

    Can someone point me to where i can find the definition of DATE OF SERVICE I know it has to be defined somewhere but have yet to find it in ICD book, CPT, or CMS. Maybe I have just overlooked it but I really need an official definition. Thanks in advance
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    Aviacode looking for REMOTE Coders

    Jennifer your email address is not working. I have tried several times to get my resume to your company and always get this response: Delivery to the following recipient failed permanently: Have any idea why I am getting this response? My contact info is...
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    Employer Assessment Tests

    remote testing I have had the same issues with this remote testing. Sounds like several of us have applied with the same companies after reading the post. My latest test was from Bonnie and I have yet to hear back from her. This will be the 3rd time I have tested with her only to hear from her...
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    Physical Exam

    No, these are not "incident-to" encounters. These are Medical Assistants some certified some not that are performing Physical Exams on all E/M levels for the mid level providers. 1 Physician's Assistant and 2 NP's. It has always been my uderstanding that the provider has to do the PE. Is...
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    Physical Exam

    Hi guys, Hoping someone can point me to the right place. Our providers do not think they have to perform their on PE's. I know I have read this and was taught in school that MA's and others can take the HPI, PFSH, and even the ROS but the Provider actually has to do the PE. Can someone please...
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    Plantar fasciitis

    Debra, Thank you for your response. Can you give me some idea of what the Provider would need to document? Do they actually have to specify plantar faciitis in the progress notes or treatment plan? I am not used to dealing with this type of documentation from a provider. Thanks
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    Plantar fasciitis

    Hello, Hoping someone can help me with this. We have a chart that the provider did a plantar fascia injection on. In the chart it states foot pain, and worse when walking, then in the progress notes it states "still has mix cramps L foot --ttp over her L facia anterior" can I code plantar...
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    ROS question - Does anyone know CGS Medicare's

    Trailblazer does not accept the "all others negative"
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    Level one F/U

    the time is spent teach the pt how to operate the Tens unit. Does that qualify? Thanks
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    What is my liability

    I recently started a new position in a medical office, but not specifically as the coder or biller and not sure what my exact title is. Anyway, the office uses superbills (charge sheets) and I do get those together and fax the off. Sometimes I do have to pull charts and being a coder I have...
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    Level one F/U

    Question. has anyone billed a level 1 office visit with a Tens F/U. Do I need a -25 modifer? This is for a pain clinic and pt is MCare. This is what it would look like 99211 (25) E0730 Pt is not seen by MD or NP for the Tens F/U. Thanks in advance for the replys. Stacy
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    Downcoding due to Medical Necessity?

    Agree with gkarow. MDM is the driving force for the E/M level. It's great you have a provider that is such a good documentor (not sure thats even a word, lol). I have some that make it tough to even get a level.
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    CPT restricted to certain POS codes

    do some searchs on the OPPS and the PPS payment systems. It's been awhile but I believe this is how I found the information I was looking for with certain CPT codes coupled with POS. Good luck.
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    Is there anyone out there that can help me this type of coding? if so you can email me at with the Title in the Subject line. All help is appreciated and welcomed. thanks
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    601.9 is unspecified prostatitis (prostadynia)
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    Infusion/Hydration coding does anyone have a tool or something that would be useful for Infusion and Hydration coding. I am new at it and need some help. My email is: Thanks,
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    infusion or hydration

    Infusion/Hydration coding anyone still have a copy of this cheatsheet? Could someone please send me a copy? thanks
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    PFSH: from each category?

    you are correct, Greg.
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    Second request... Pain management

    the ortho surgeon would bil for the line placement. the anesthesiologist would then bill for the management.
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    help with elements

    you have 4 elements in your HPI: Context, Duration, Associated Signs and Symptoms, and Modifying Factors. Your CC is: "not eating or drinking" Context: worried pt may be dehydrated Duration: for the last week Asst S&S: no pain no nausea Modifying: metastic breast cancer
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    ED Coding ICD-9

    Hi, I was hoping someone could help me. I am looking for a webinar course for ICD-9 coding for the ED. I found one at Coding Metrix but they have discontinued that one. Has anyone on here taken or ran across one of these lately. I am having difficulty in finding much of anything to do with ED...
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    ER--patient treated and returns for recheck

    the key to this one is the pain meds given and the dressing was changed. You would bill an E/M level. you did not specify if this was MCARE or commercial. Someone else posted some good info regarding MCARE. Most of the time you will code an E/M level for commercial follow-ups. There are no...
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    Shoulder Dislocation

    If you are coding for the EDP then you would code the pain, the current dislocation of the shoulder, and then seizure. You will code to the appropriate E/M level for the EDP. Since the Ortho did the reduction you do not code that procedure. 831.?? 719.41 780.39 or 345.90 then the E codes As...
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    need CPT Help..Please

    avulsion toe nail. digital block...then hemostats were used to place the avulsed nail, back into the nail matrix, a cautery was used to drill a hole in the nail, a pressure dressing was applied. This is the procedure that was done. what CPT code do I use? Thank you
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    Wiki abdominal pain and pregnancy in ED

    Everything is a complication of the pregnancy unless the physician states otherwise. Please review Chapter 11 guidelines.
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    Help with E/M coding in the ED

    The hospital coding is different from the pro-fee. The hospital may be a level 3 and the physician (pro-fee) coding my be a level 4. Yes, the hospital will submitt charges for the same day with the same dx for the same pt. Are coding for the hospital or the pro-fee side?
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    Pt is seen in the ED by who the EDP or his/her PCP? Who are you coding for the EDP or the PCP?
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    ICD 9 for ED

    I would not use a Psych code unless it is specifically stated in the chart.
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    new coder needs help with HPI

    who documented the CC? If it was not the MD you can't count it in the HPI. I see 4 here in what is documented. Context, timing, Associated, and Modifying factors.
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    Online Coding "Book"

    Hi, Does anyone know of any other online coding "books" besides Encoder but are similar? Any web based or downloadable program information is appreciated. Thanks, Anastacia Sims, CPC
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    Help needed for Anesthesia billing

    Some carriers are not paying times/units for epidurals but are paying a flat rate instead. I would call the carrier and find out what their policy is for delivery epidurals. Anastacia Sims, CPC
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    Toe Walking

    look at 781.2.
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    Kidney Fracture dx???????

    Try 866.?? section. If that is all you have from the physician I would have him/her clarify.
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    Tooth trauma

    873.63 would be the dx used for trauma/injury. If you look in the Index to Disease under Injury then down to tooth NEC it leads you to the above dx code.
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    Er 99281/no ros done

    Here is a link from ER coder about "double dipping" http://
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    Er 99281/no ros done

    Yes, you can take ROS from HPI. So remember you always have at least 1 ROS because it comes from the HPI, assuming your EDP at least restates your CC in the HPI. All you need for 99283 is one ROS. Do you have an auditing tool? I know someone used the term "double-dipping" but this is not...
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    ER Code/Charge for DOA

    I would ask the ED group. Some ED physician's groups do not charge for a true DOA, no intervention at all. If the ED physician did any intervention then yes, normally a low level.
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    ER Trauma ER Emergency NEW NEED HELP

    The above answer should help you when coding CC. The E/M codes used for ED are 99281-99285. You will also use a variety of CPT codes when coding ED. You will see a variety of vistis ranging from "worried well" to critical care.