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    Hypertension with Cardiovascular disease I11.9

    Hello, I am not strong in cardio :). I am trying understand what constitutes the use of this code. If patient has ASHD, Arteriosclerosis, Cardiomyopathy with hypertension I am thinking that it is possible these can be tied in to the I11.9 if no heart failure. Can they? or not? Do you have...
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    Hypertension with Cardiovascular disease I11.9

    Hello, I am not strong in cardio :). I am trying understand what constitutes the use of this code. If patient has ASHD, Arteriosclerosis, Cardiomyopathy with hypertension I am thinking that it is possible these can be tied in to the I11.9 if no heart failure. Can they? or not? Do you have...
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    Medicaid Modifier for Aliens (MLA) Florida

    We are getting denials for Florida Medicaid deliveries for emergency Medicaid for Aliens. They are denying the vaginal deliveries for a required modifier?? I have not seen a modifier for a vaginal delivery? Thanks,
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    TCM w/Evaluation and Management

    If justified/documented. Can a physician code a TCM code with a E/M. I am looking at CCI and do not see a edit nor do I see a exam component to the TCM. I am thinking yes if necessary but want to double check. Thanks! :confused:
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    TRANSISTIONAL CARE MANAGEMENT w/ E/M service

    If justified/documented. Can a physician code a TCM code with a E/M. I am looking at CCI and do not see a edit nor do I see a exam component to the TCM. I am thinking yes if necessary but want to double check. Thanks! :confused:
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    BH Diagnosis

    I am new to this specialty on top of having to handle how Medicaid prefers to use H codes(I think I have this under control) :) But, we are trying to get a handle on the diagnosis codes as to which codes they are covering. Can anyone give me some insight as Medicaid is very vague and does not...
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    retroplacental hemorrhage/vaginal bleeding

    Please help! The op report (c-section) indicates: Vaginal Bleeding but the procedure description indicated "some evidence of retroplacental hemorrhage at the time of placental removal" Can you help with coding of the retroplacental hemorrhage? The codes I was looking at was for premature...
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    Retroplacental hemorrhage/vaginal bleeding

    Please help! The op report (c-section) indicates: Vaginal Bleeding but the procedure description indicated "some evidence of retroplacental hemorrhage at the time of placental removal" Can you help with coding of the retroplacental hemorrhage? The codes I was looking at was for premature...
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    OP report/procedure not listed

    Good afternoon, I am trying to code a Operative report, the provider has left off the name of procedure. I know what was performed but is this acceptable? or should I request the provider to addend the report? Thanks,
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    Annual GYN Exam no pap

    If a patient comes in for annual gyn exam not including a pap(just a breast and pelvic exam). Should the preventative medicine code be used? If not what cpt code do we bill? I am thinking the preventative as it is just preventative. The provider is saying no and is concerned that the patients...
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    Robotic Total Lap Hysterectomy/lysis of adhesions

    I need a opinion. The Operative report indicates "began by removing some relatively dense adhesions of rectosigmoid colon to the left tube and ovary into the cul-de-sac as well a the posterior uterus. I think if justified we can code to lysis of adhesions correct? IF so, do you feel it is...
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    Delivery of placenta vs Curretage

    Good Morning, I am a little confused on this one. Patient delivered at home and a attempt to deliver the placenta with out success. The physician brought the patient to the OR to attempt to deliver placenta. He again attempted to deliver placenta without out success and then used a sharp...
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    Assistant Surgeon dictating note

    Hello, It is appropriate for the Assistant Surgeon to dictate the note rather than the main surgeon? I am not sure if this is a error or not. Thanks
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    Deliveries with lacerations

    Hello, I have not done coding for deliveries for a while and need some help. With Vaginal deliveries not complications it should be coded 650, V27.0. If the patient had a perineal laceration during delivery, should this be coded rather than the 650 Normal delivery? I want to make sure I am...
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    Medicare Review Audit

    Good Morning, Has anyone appealed a Medicare focused review? I have a provider where Medicare did a review and has down coded many of his visits based on Medical necessity. I understand on many of them the justification, but there are several which I am agreeing with the providers coding...
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    Accuracy of coding decline

    Good Afternoon/morning! I do post payment audits to track the accuracy of our physician coding and educate them but for the last few months I have seen a decline in the accuracy of their coding. I am at a loss and was wondering if anyone can make any suggestions of where to start. I generally...
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    Florida Medicaid HCPCS Codes

    Good Afternoon, Florida Medicaid has provided us with a listing of HCPC codes they accept. I am trying to figure out the documentation requirements as some I can not find the CPT match. I hope this makes sense as I want our providers to be able to provide proper documentation for the...
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    Hpi

    The document has 2 problems in the HPI, both explained quality for each. I had a physician tell me he can count 2 points for quality. I disagree. I am counted the second problem as a associated sign and symptom and only giving one point for quality. Should 2 points for quality be counted in...
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    Should Edema be coded

    Maybe I am having a brain fart! :) The physician coded edema on the visit. The exam indicates "Extremities without clubbing, cyanosis, or pitting edema. It does document that the last visit he ordered Ted hose for edema but the patient did not comply with treatment. The documentation...
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    Diagnosis coding of Follow Up ER

    :confused: We have a record which the provider indicated a fall but does not state injury. We have the documentation from the hospital shows the injury. Can we use this for coding or ? I know we can not just use a E code Thanks,
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    Dermatopytosis 110.0

    :confused:Hello All, Maybe you can help me. I am sure there is some reference you can refer me to. Medicare is denying this diagnosis code as non covered. I know there is something, I just cannot find it. This is for a office visit, I am trying to find a reference for this. I went to the...
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    Dermatophytosis 110.0

    :confused:Hello All, Maybe you can help me. I am sure there is some reference you can refer me to. Medicare is denying this diagnosis code as non covered. I know there is something, I just cannot find it. This is for a office visit, I am trying to find a reference for this. I went to the...
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    Pap only visit - preventative med

    A patient came for a preventative med visit. She came back a few days later for the pap. How should the pap visit be coded? It is not a preventative med visit nor a problem focused visit. Any thoughts? TIA
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    Pap only visit

    A patient came for a preventative med visit. She came back a few days later for the pap. How should the pap visit be coded? It is not a preventative med visit nor a problem focused visit. In the past we coded just a problem focused visit. Any thoughts? TIA
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    "Appers to be diagnosis"

    Good Morning, I am reviewing a documentation and the provider notes "appears to be seborrheic keratosis" I am saying that this is not a confirmatory diagnosis, and should not be coded as seborrheic keratosis. What are your thoughts? Thanks, :confused:
  26. E

    Mycosis

    Medicare is denying our visits for not medically necessary for 110.9 and 111.9. It does not seem correct as these were office visits and the provider did prescribe treatment. Since I normally do not handle derm maybe the experts can help me :)? Doesn't seem quite right. I did try to see if I...
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    Dermatophytosis and Dermatomycosis

    Medicare is denying our visits for not medically necessary for 110.9 and 111.9. It does not seem correct as these were office visits and the provider did prescribe treatment. Since I normally do not handle derm maybe the experts can help me :)? Doesn't seem quite right. I did try to see if I...
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    Signs and symptoms/definitative diagnosis

    Hello All! Base on the guidelines I know if there is a definitive diagnosis you would not code signs and symptoms the are a integral part of the diagnosis or routinely related. So if for example: URI sometimes there is fever but not always, would you code the cough and the URI or just the URI...
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    Diagnosis codes when dr is not managing condition

    Good afternoon, If the doctor is not medically managing a condition or does not address the condition I was told not to code it. Is this correct? The physician has listed this in the list of problems as this is a multispecialty group but he is not addressing it. I am being told I need to...
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    Centricity and Coders

    Good Morning, We are entertaining the idea of having the physicians document and care for the patients and employ coders to do what they do best(Novel concept huh?). This seems simple, but I am trying to figure out how this would work with our EHR as the diagnosis are linked with the code...
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    CENTRICITY EHR and Coders

    Good Morning, We are entertaining the idea of having the physicians document and care for the patients and employ coders to do what they do best(Novel concept huh?). This seems simple, but I am trying to figure out how this would work with our EHR as the diagnosis are linked with the code...
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    Auditing of Incident to

    We recently have started employing Nurse Practitioners and PA's. I am trying to make sure our records are correctly showing when a service is a "incident to". Our providers are signing off on the charts as well, but is this sufficient? I would think they need some type of wording or proof of...
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    Auditing incident to

    We recently have started employing Nurse Practitioners and PA's. I am trying to make sure our records are correctly showing when a service is a "incident to". Our providers are signing off on the charts as well, but is this sufficient? I would think they need some type of wording or proof of...
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    Naltrexon Insertion(not injection)

    confused: Help This is a new procedure for me. Do you know how to code for a insertion fo a Naltrexon Pellet? This is placed in the abdomen in the deep subcutaneous tissue. Apparently it has been approved for treatment by the FDA, but I can not locate a code. Thanks in advance. Kim
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    Surgical Procedures in Office

    There are times when our doctors after seeing a patient does a minor office procedure. Do you know where I can get any guidence of how it should be documented? I am saying they need to docuement the details of the procedure, all that has been documented is XYY procedure performed. I do no...
  36. E

    Coding Metastatic Cancers

    Hi, I have question as I am coding a chart which indicates "recurrent and metastatic uterine adenocarcinoma with metatasis to the lung" The lung is secondary correct? the uterine is primary? But if the patient had a Total Hysterectomy years ago for the CA and the record indicates that it has...
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    Forms for disability

    Does anyone know if there are some rules on charging for completion of forms for disability? I do know providers do charge at times for this time. The fed register indicates charging for copies of Medical Records and the charges for, but what about charging for the doctors time to complete...
  38. E

    Destruction Lesion(polyp) mouth

    Help I need help on this code the doctor did this in the office using cautery. I am not sure if 40820 is correct or not as this is out of my specialty. Thanks!
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    E/M Visit Auditing Ob Visits Help!

    I am trying to audit our Ob visits(we do not do the delivery and bill out per visit mostly Medicaid patients or self pay). I have a reference from a conference the CMO went to and it indicates that most Ob visits are generally a level 3 visit(based on documentation). History Brief...
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    Pediatric Visit - Patient not Present

    Parent wants to come to the office only to talk about their child, is this something which has a code. I have read that time can be used with a visit code however I am not confortable as what I have read time is to be use when the counseling and cordination of care dominates 50% of the visit...
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    Auditing Newbee

    I am new to auditing and trying to get things together as I have taken on a new role. I am taking the NAMAS auditing class this weekend and I am hoping to learn alot! I am using the 97 guidelines and have a question regarding the exam: When the doctor indicates "Face exam normal". I am not...
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    Providers Billing for Labs done at the Lab

    I am not sure of this but can a provider code and bill to a third party payer for labs they send out to a laboratory? Someone was saying they can if the use modifer 90 but I was udner the impression this is used if the lab sends it elsewhere. Please help me. Thanks.:)
  43. E

    55400 vs 54900

    Could someone explain the difference between the two as the classbook step by step has confused my students as well as myself. pg 589 55400 it is a procedure to remove obstruction form the vas deferens. Once the area is identified, it is removed and the ends of the vas deferens are...
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    Exposure to Hepatitis inutero

    Does anyone know what ICD-9 code would be appropriate for this. Baby born to mother with known Hepatitis. Thank
  45. E

    Observation more than 2 dys

    which codes would be used for a observation status when the patient is in for more than 2 days Like 4? I understand how to code the initial day and the discharge day, but what about days inbetween? Thanks, Kim:)
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