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  1. K

    final diagnosis coding

    I'm wondering how other facilies are handling these situations. When a patient presents with an elbow injury due to a fall, the physical exam is specific to the elbow, and elbow xray is done, but then the clinicain has a final impression/diagnosis of 924.9, contusion of unspecified sites. Are we...
  2. K

    Fracture vs sprain

    I'd interested to know how others handle this scenerio. When a patient presents to the ER and the ER clinician diagnosises visit as a sprain, then after patient leaves, the radiologist views the xray, reads it and diagnosises it as a fracture. What are you putting on the bill for the ER visit...
  3. K

    Flu-like symptoms

    If you look under influenza-like disease, it directs you to 487.1
  4. K

    Outpatient facility levels

    Is anyone familiar with the Lynx Medical System, specifically the E/point system for facility coding? If you use it, what do you think of the system? Do you find the charging algorithm to be accurate?
  5. K

    Accidental Needle Stick

    Now I'm curious, we've always coded V15.85 along with the E code for needle stick. Wondering how many others use the open wound codes as the primary dx?
  6. K

    Burn treatment

    I code both the facility and professional charges in our ER. When a patient comes in with burns, it is generally our nursing staff who applies the dressings. My question is, if it is the nursing staff doing the procedure, is it correct or incorrect to allow the clinician to charge as well? My...
  7. K

    Nst 59025

    Even if there were a print out from the machine, doesn't there have to be an interpretation from the doc in the form of a dictated note?
  8. K

    Nst 59025

    Hi, Is there anyone out there who could help me with documentation guidelines for billing 59025. This is for an NST. Thanks!
  9. K

    Icd-9 procedure coding

    I am thinking you mean Volume 3 icd 9 procedure codes? That is a good question! I'd am curious about that too!
  10. K

    removal of fish hook from finger

    I agree with PeaPod, if there is no documentation of an incision, we can't code the foreign body removal. We capture the time spend in the E&M level.
  11. K

    CPC Exam is tomorrow help needed

    Don't ponder on any one question too long. If you are having trouble, move on to the next one. You can go back and look at those troublesome questions when you've completed the other questions. Good luck to you!!!!!
  12. K

    Vunerable adult

    Is anyone aware of a code that can be used when the phycisian indicates "vunerable adult" as one of his final diagnosis? Thanks in advance for any help with this!
  13. K

    New coder needs help

    I use this forum quite often and get lots of good information from it. I have to admit I was quite shocked with Preserene's above statement to Brandi. I think it is in terrible taste to talk like that and quite frankly puts a big black mark on any credibility that preserene might think they...
  14. K

    Elevated Liver Function Tests

    I'm good with the physician has to document that the liver function test is abnormal to use it as a dx for the encounter. What about on the facility side, if you see the lab as being abnormal, but the doc doesn't use it in his final dx, can you pick it up and use it? Thank you in advance for...
  15. K

    Elevated Liver Function Tests

    Maybe I'm wrong, but doesn't LFT stand for liver function test? Why wouldn't you code abnormal function study, liver 794.8?
  16. K

    diabetes coding

    If a clinician states Diabetes, poor control would you code that as "uncontrolled" or do you only code that when the clinician specifically says the word uncontrolled? Thank you.
  17. K

    In need of QA

    use the exacerbation of COPD code.
  18. K

    newborn billing question

    That's the way we figured it should be billed, Thanks Tessa!
  19. K

    Newborn E/M questions

    Thanks for your research on my question Jodi!! I really appreciate you taking the time to help me figure this out. :D
  20. K

    Newborn E/M questions

    I had posted this question in a couple different areas of this forum and have yet to recieve a reply. Since you are familiar with newborn coding, would you know the answer to my question? I was wondering how to cpt code a newborn that is normal the first 2 days (99460 & 99462) and then on the...
  21. K

    newborn billing question

    I was wondering how to cpt code a newborn that is normal the first 2 days (99460 & 99462) and then on the 3rd day has tachypnea. Do we then code 99477 or 99480 or would it be 99221-99223?
  22. K

    Newborn billing question

    I was wondering how to cpt code a newborn that is normal the first 2 days (99460 & 99462) and then on the 3rd day has tachypnea. Do we then code 99477 or 99480 or would it be 99221-99223?
  23. K

    Takken the CPC exam? How many passed the 1st try?

    I passed my first time. I had 7 years of coding experience and did not do any sort of schooling. The test was a challenge, and I passed with an 87 with only 20 minutes of extra time left for the test. Now I understand they allow you more time for the exam. Good luck, think positive!!!
  24. K


    what about code 92960?
  25. K

    Uterine contractions -Pregnant

    Take a look at 644.0x. "Threatened premature labor after 22 weeks, but before 37 completed weeks gestation">
  26. K

    Elevated Troponin or CK's

    I work the ER accounts at our facility and I use 790.5 also for elevated troponin.
  27. K

    2 hours 50 min of hydration in ED

    Here is a "cheat sheet" that I obtained thru an AAPC conference that was held in MN awhile back. Hydration Duration Times 31 minutes to 90 minutes bill 96360 91-150 minutes 96360 & 96361 151-210 minutes 96360 & 96361 x2 211-270 minutes 96360 & 96361 x3 etc each add'l 59 minutes Note, this is...
  28. K

    2 hours 50 min of hydration in ED

    Start and stop times are required. If you have no stop time, the most you can bill is a push is what my understanding is.
  29. K

    precordial catch syndrome

    Does anyone know of a more specific dx code for this besides 786.50? Thanks!
  30. K

    acute on chronic renal failure

    That's what I was thinking, but just wanted to bounce it off of someone else. Thanks for replying! :)
  31. K

    acute on chronic renal failure

    Can anyone help me with a dx code for this? Thank you in advance for your help!! :)
  32. K

    Nashville Flooding

    My thoughts and prayers are with you through this awful time for your city.
  33. K

    OB package billing

    Thanks for your reply Heidi. It's nice to get feedback. It's such a "gray" area of coding that's its good to hear other coders points of view.
  34. K

    OB package billing

    When a patient presents to the birthcenter with say for instance, braxton-hicks contractions or feared spontanous rupture of membranes, and is sent home after evaluation, is it appropriate for our physicans to bill and E&M level outside of the global package?
  35. K

    Wiki when patient leaves the E.R. without being seen?

    Our facility does charge a minimal level for triage time and we code with a dx code of V64.2.
  36. K

    ICD 10 Workbooks

    Is anyone aware of any self learning ICD 10 workbooks that can be purchased?
  37. K

    Infusion times???

    That's a great question, we occasionally see that happen in our ER and I'd be curious what other people thought about this. I would think you could code the infusion based on what is documented, but maybe the "no stop time" is will result in a push only code.
  38. K

    ER - Coding knee immobilizer

    correct me if I'm wrong, but I code facility ER and when an "out of the box" knee immobilizer is used, we only code the supply not a splint application of 29505. Does anyone else agree with me?
  39. K

    critical care facility reporting

    So do you remove the bundled items completely off the bill or would you still report with a $0.00 charge?
  40. K

    Nursing Documentation Requirements

    I approached our ER nursing supervisor and explained we were potentially losing hundreds if dollars a day of lost revenue if the nursing staff does not document start/stop times. It worked! Our nurses do an awesome job at it now!! Money talks :)
  41. K

    Nerve Block

    We use 64400 also for dental pain
  42. K

    Encoder - We're looking into getting an Encoder very soon

    I've been a user of Encoder Pro for a long time. I have to agree that its a great product. Not sure what I would do without the anesthesia crosswalk that it has. I love that!
  43. K

    NST documentation

    Does anyone know the documentation requirements regarding NST's? Is a clinician order enough or should there be a dictated note. Thanks in advance!
  44. K

    dx code help

    What would you use for a diagnosis for "acute on chronic back pain"? Would you code BOTH codes? 724.5 and a chronic pain code?