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    IV Infusion and IV Push CPT Codes.

    A patient was infused with Rocephin for 1 hour, then was given a IV Push into the left anterior cubitus. I was informed to code procedure as 96365 for infusion and 96375 for IV Push, not 96374. Can someone verify if this is correct coding? Thanks so much.
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    Nebulizer Treatments

    Are medical assistants able to provide neb treatments and if so would the billing and payment for administering the neb treatment be the same amount as if a Respiratory Therapist administered the treatment in the outpatient dept? All answers would be greatly appreciated. Thank You.
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    Eyeglass repair

    Is there a ICD-9 Vcode for this? New to eye clinic coding. Thanks.
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    Uncontrolled dm with no lab workup.

    This PA always assigns ICD-9 codes for Diabetes. The latest entry is diabetic foot ulcer-uncontrolled. This patient was seen today. No labs were drawn for today's encounter but in looking at previous labs (09-19-12) glucose levels were high-270. Based upon those lab values todays encounter is...
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    Ppd readings

    This is usually a nurse visit only when patient comes back to clinic to have their ppd read. In this instance must a provider (MD,PA-C) sign off on the progress note? Thank You for responses.
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    thanks for ALL the responses and HELP. This is a great site for answers to yer questions!
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    T system forms

    T-SYSTEM. Do any coders use this form in their place of employment and if you do I have a question for you. There are 2 forms. One for the nursing staff and one for the physician. The nurse always fills out intake form then she fills out the CC and PFSH for the provider on the PHYSICIAN RECORD...
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    If a physician sees more than 4 patients in one day, all diagnosed with "URI" and the same medications are given to all,(tessalon,pseudoephedrin,motrin) does this encounter become less complex and the appropriate CPT code for "limited complexity" apply? CC and ros,exam, are almost identical for...
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    No chief complaint - chronic conditions

    Patient is 64 y.o. estab.patient with 2 chronic conditions, HTN and DM. DR. states in his HPI patient has no complaints and no new problems. For his assessment the Dr. assigns HTN and DM. Would this be coded as preventive med. 99396? Thank You for your answers.
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    V68.1 as first listed diagnosis

    Is anyone using v68.1, issue of repeat prescriptions, as a primary dx., in the absence of a chief complaint for patients who have no complaints? We have patients who present for medication refills only for their chronic conditions, ie.,DM,HTN,CAD,etc.
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    Coding e/m for pod.

    I've never coded podiatry before. Can anyone tell me if all three key components (History,Examination,Medical Decision making) is required for a New patient visit? For History, must a new patient visit have all 3 documented?:medical hx,social hx, family hx? Thank You.
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    Podiatry e/m

    I'm new to coding podiatry encounters For new patients does there have to be a complete medical,family,social history included in the POD. progress note? Thank you for your responses.
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    Hpi,ros,exam templates

    Our physicians use a template where they circle the elements of a HPI,ROS,and EXAM. More often than not they'll circle everything even though those systems/body areas aren't pertinent to the CC. In this situation would it be correct to count those systems/body areas to arrive at an appropriate...
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    Constipation with encoporesis.

    This is the Dx for 8 yo. Does this seem possible? Requesting opinions.Thank You.
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    Muscle Strain-current of old?

    I would appreciate your suggestions on how to code a muscle strain that occurred 9 months ago, 11/08. Patient is being treated and this is his first encounter with health providers. Do I code for a current acute condition or code the "old/chronic", 718.91: Unspecified derangement of joint. Thanks.
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    Patient comes in for PFT. No assessment is performed by provider. The only indication that shows patient is in for PFT is an order slip which states"poorly maintained asthma". Patient is sent to respiratory therapy and PFT performed with codes 94010,94510,94375,94664 assigned by therapist. A...
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    Preoperative exam

    Patient presents for preop. exam. No condition is mentioned which requires the preop exam. No ROS is performed. 7 systems are checked for the PE portion. Am I correct to assign an office visit E/M code and not preventive med.? Thank You.
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    Preoperative Exam

    Patient presents for a preop exam. No condition is mentioned. (HPI). No ROS is performed. 7 systems are examined and EKG was done. Assign preventive medicine code or e/m office visit? Thanks.
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    No CC, with chronic condition

    Would the first listed be the V code followed by the chronic conditions or just the V code itself be first listed. Appreciate the help. Thanks.
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    No Chief Complaint

    Hello, I'm interested to know how some of you would code this visit: CC:Patient presents for med refill. He states no complaints. Provider assigns DM,CHF,HTN as his clinical impression Lab work for A1c is done, a ROS and Phys.Exam are performed and medication for his chronic conditions are...