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    "Valid" Physician Orders

    Does anyone have documentation regarding a specific format, form, or documentation requirements (other than signature, date and time for all services ordered) for physician orders. We have a concern regarding the fact that we have a group of providers who are not using any particular format...
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    PA as assistant at surgery

    Can we use the assistant at surgery modifier 80 for Physicians Assistants, or is there another more appropriate modifier for this if not?
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    MDM established problem (to examiner)

    If a patient sees Dr A on Monday for knee pain, and then follows up with Dr. B due to worsening pain(both in the same practice), is this considered a new problem or an established problem? I believe that MDM states new problem to examiner.....
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    Subsequent hospital visits

    When a physician sees a patient on a subsequent visit, what should they document for this interval history with regards to the HPI? I maintain they must refer to the last time they saw the patient, it does not have to be a specific date, instead they can reference the previous visit with a...
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    Night resident note

    Please help with this scenario as presented to me by a collegue: Night float resident sees the patient late evening and does an H&P for the admission, The teaching faculty physician receives sign out and sees the patient with his/her team of residents in the morning and decides that the...
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    Readmissions within 30 days

    If a patient is readmitted within 30 days of an inpatient stay for the same diagnosis what are the rules for coding the initial day for second visit the physician? Any official source info would be helpful.
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    NDC # for mixed chemo drugs

    Does anyone have any information for what is needed to report NDC drugs for chemo drugs that are mixed? I read somewhere not sure where, that they must all be reported however I am getting some push back from the practice that states that they do not need to do this.
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    Inpatient rehab medical management

    Hi All, Our hospitalist's continue to see patients that have been transferred to an inpatient rehab unit within the hospital. The patient has been transferred officially out of the inpatient unit, and is being managed for the rehab conditions by the rehab physician, the hospitalist is managing...
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    Help please on follow up visit for lab results

    If there was a stupid question, this may be one of them. I am relatively new at OPT coding so bear with me. I have a physician who wants to bill for an office visit when he sees patients for follow up of lab results. He states he always sees the patient in the office following a lab result...
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    Physcian coding or Coder coding?

    For all of you involved in cardiology practice management- I am building a pro fee cardiology coding team. In order to justify the need for a coder I am tasked with trying to find industry standards on who is responsible for the coding inpatient, outpatient, interventions, etc for...
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    Teaching Physicians supervising residents of another specialty

    Does anyone have any links to documentation that states that a Teaching Physician can or cannot supervise a resident in another specialty. I understand that there is a qualification issue, but I need something that states that they either can do this or can't. I have searched for hours now and...