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    Modifier ST - relation to trauma and injury

    Fellow AAPC Professionals: I am seeing modifier ST appended to radiology services in the outpatient settings for patients who have had an injury. This is happening for United Health Care Choice Plus. Does anyone have any information on whether this is appropriate use of this modifier for this...
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    Billing for an Inpatient Stay

    Hello Fellow AAPC Coding Professionals: I am working on an audit and am not familiar with billing for critical access hospitals. A patient is admitted for five days and is seen by three different hospitalists. All five encounters are billed under the discharging physician. Is this correct...
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    Interesting use of EMR - any thoughts?

    Hello fellow coding professionals, So, got a client that uses the transcription/EMR combination. The HPI exam and MDM are dictated and then pulled into the note by the midlevel. The LPN completes the ROS and PFSH. The CODER (yikes) pulls the ICD codes into the assessment and plan. Each...
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    Decision for Surgery within global period

    Hello Fellow Coding Professionals Patient had surgery for greater tuberosity fracture with shoulder dislocation and is in the office during the global surgery. There is a displacement of the greater tuberosity fragment and a decision for ORIF is made. Is this a billable E and M since the...
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    414.0?

    Hello Fellow Coding Gurus, So we are debating on the correct code for the following documentation: CAD (coronary artery disease) of artery bypass graft CABG was in 2003. No stents in over 1 year. Will hold Plavix and aspirin so patient can have port placed My thought was 414.04 because...
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    Ejection Fraction

    When coding for an E/M service, is a low ejection fraction considered high risk? Thank you
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    Physical Exam

    I have a teaching physician scenario where the fellow documents the MDM only. The attending does document a compliant attestation and indicates he saw and examined the patient with the resident. The findings of the exam are not documented by the fellow or attending. I do see this portion in...
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    Leveling of E/M without the Marshfield audit tool

    Hello Fellow Coding Professionals, One of my clients recently pointed out that Medicare does not use the Marshfield clinic audit tool. They pointed to the 95 guidelines and indicated they do not use the point system when determining the level for dx/tx options. Does anyone have a strong...
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    To Bundle or not to bundle and procedure ?s

    Hello Fellow Coding Professionals, Tryin to tackle some dermatology here. I am wondering what are the documentation requirements for 17111? Is the provider required to state the location and number of lesions? This is what the provider documents: Flat topped verrucous papules (vs stuck on...
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    Preventive, Breast Pelvic, and Pap for Medicare Patient

    One of our coders made the point that our providers' document a preventive service plus a breast/pelvic exam (G0101) and a pap (Q0091) for Medicare patients. Her experience is that the preventive can still be billed although not payable by Medicare. If the patient has a secondary such as a...
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    Balance Billing Past Timely

    Hello Fellow Coding Gurus, So my mom has Medicare/Tricare and recently decided to get a second opinion. She requested records from the PCP (who required a $50 fee to distribute) and interpreted the request as transferring care. They decided to slap her with a $200 bill for a G0439 service...
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    E-codes on CMS 1500

    Hello fellow coding professionals, I have heard that e-codes should not be used on CMS 1500. However, I thought they were required according to ICD9 guidelines. Can anyone confirm that e-codes do not need to be used on the professional bill? Is there a reference? Thank you Sparkles
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    Diabetes Education

    Hello fellow coding professionals, I am wondering if anyone knows if G0108 and G0109 require start and stop times? Is it acceptable to just document the total time? Thank you
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    Preventative Medicine in Oncology Practice

    Hello Fellow Coding Professionals, Just wanted to get a feel on this scenario. Patient has history of cervical cancer and returns to their oncologist for surveillance. Provider considers this a well woman exam, performs an E and M and pap, and bills preventative. Has anyone seen preventative...
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    Borderline Personality Features

    Hello Fellow Coding Pros, Does anyone code borderline personality features as 301.83? Or should disorder be specified? Thank you!
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    Preventative not met

    Hello Fellow Coding Gurus, Patient presents for preventative medicine. The provider notes history of hyperlipidemia and orders labs. Also completes a comprehensive history and exam. This does not really satisfy preventative, as the provider does not document any counseling/anticipatory...
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    Date of Service

    Hello Fellow Coding Professionals, Our providers often use the date of admission field to capture the DOS. However, these are outpatient charts and there is a date of service field as well. We have attempted to educate, but they do not feel like it makes a difference. Does anyone have...
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    88150 Question

    Dear Fellow Coding Professionals, I was reading through prior threads on 88150 and noticed it appears to be a code billed by the laboratory. I have a client that performs their labs in house. What documentation requirements should be met to bill 88150? They are just stating pap was done -...
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    Opinions please - shared visits

    Dear Fellow Coding Professionals, I have a client that wants to code shared services. They are a hospital based outpatient clinic and incident to does not apply. Do you think the following statement is acceptable? The NP dictates the note and the physician follows with this statement: "I...
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    Medical Necessity

    Hello, Just wanted to get some coding opinions on this one. Patient presents to a large multispecialty hospital based practice. Patient has an appointment with cardiology, but the appointment scheduler accidentally scheduled patient with orthopedics. Patient shows up to see orthopod who sees...
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    status post CABG

    Hello fellow coding professionals, I am reviewing the AHA Coding clinics for patients presenting status post CABG, but am still somewhat confused. When documentation states status post CABG, but does not mention CAD or atherosclerosis, how should this be coded? Thank you!
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    Non teaching physician hospital

    Dear Fellow Coding Professionals, I have a client that is saying that resident and student notes can be used by the physician because they are not a teaching hospital. I could understand the resident, but to me the student note is a red flag. Has anyone else heard of this and do you know of...
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    HPI in the MDM?

    Fellow Coding Professionals, One of the auditors I work with indicated that if we can not find enough HPI elements in the HPI portion of the note, but find it elsewhere (e.g the duration of the illness is found in the MDM) that it can be counted in the HPI. This is because we as coders must...
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    Medical Decision Making

    Do you consider the following as dx/tx options? Example 1: Diabetes: cont insulin Example 2: Diagnostic Statement indicates PE and CAD PE. Continue enoxaparin at daily 1.5mg/kg dose Statement that patient has multiple comorbities with no changes at this time. Would you count the...
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    Discharge

    If a patient experiences issues such as seizure during an inpatient stay, do you code this on the date of discharge if they are no longer actively having seizures? Thank you, Sparkles
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    Medical history

    When the provider has a list of chronic illnesses under medical history, but does not mention them in the rest of the note, do you code them? Example: Hypertension and end stage liver disease under past medical history. Do you code these? Thank you, Sparkles
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    Donor infection

    Patient has just had a kidney transplant and the provider was contacted by the donor network and notified that the donor had MRSA bacteremia. How do you code this? I have not been coding the MRSA bacteremia, as it is not yet confirmed in the patient. I typically code 996.81 (complications of...
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    New vs Established Preventive Medicine

    I hope this question is easy for many coders. If a patient is established to the clinic, but comes in for an initial wellness visit, do you use an established or new preventive medicine code? Thank you!:)
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    Work up - opinion please

    Our auditing team has multiple opinions on the following issue: Infectious Disease provider is consulting for possible infection and treatment. They are awaiting biopsy results ordered and completed by the dermatology department. Do you consider this a new problem with work up for the ID...
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    Medical Coding Insurance

    Good Afternoon, Just wondering if anyone has any recommendations for coding insurance? I would like to obtain a plan personally, and there was a recommendation on the AAPC site before but I am not able to find it. If anyone has a recommendation, I would greatly appreciate it. Thank you...
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    Modifier 32

    I could not find any threads started on modifier 32. I am just wondering if anyone has experience using this modifier? I am wondering if it is supportive of a consultation when mandated by a government entity such as DFACS. (For child abuse) I have found literature indicating it supports a...
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    Vaccines for children

    Just wondering if these vaccines are billable? I am receiving two different answers - bill the vaccine, but not the administration. Or bill the administration, but not the vaccine. Please let me know your policy!!!
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    EHR addendum

    We have been told by management that after the resident/fellow completes a note in EHR, the attending can do an addendum which includes basically signing off on the note, and the note is considered the attending doctor's note. The TP statement is not being enforced because they feel it is the...
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    Auditing Radiology

    How would you answer this question? Question from a rural hospital about the extent to which hospitals can bill Medicaid for the professional component of an radiology service preformed by out of state radiologists. Here is the scenario. •Hospital contracts with out of state radiology group...
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    Vitals by RN

    If vitals are recorded separately by the nurse and placed in the record, does the doctor need to initial and sign off to be able to count this toward the physical exam? The doctor dictates, but there is no evidence the doctor reviewed this information. Or can it automatically be counted as a...
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    How many minutes per chart?

    Hi, For FTE purposes, how many minutes are allowed for review of one encounter? We are given 10 minutes, but sometimes it takes longer. Just wondering what other people estimate for their jobs, and if there are any documented guidelines out there on how long it should take? Thanks, Diana
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    Electronic Audit Sheets

    We are attempting to purchase software for Electronic Audit Sheets to complete our audits of evaluation and management codes. Could some people please recommend preferred Electronic Audit Sheets and vendors for them? Thank you in advance, Diana, CPC Physician Auditor
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    HCPCS for Pediatrics

    One of our Pediatric Immediate Care centers bills HCPCS codes. None of our other sites do. Does anyone in Pediatrics bill HCPCS codes??
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    Infants

    For a multispecialty clinic, infants are seen in Craniofacial Department to evaluate newly diagnosed cleft lip and palate. Afterwards, the parents and infant talk to the psychologist. The psychologist evaluates the parents stress and reaction to baby with this diagnosis. What psychotherapy...
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    Critical Care and ED Same Day

    One of our ED physicians sent me a FAQ from the American College of Emergency Physicians indicating CC and ED can be billed on the same day. Is there a resource(besides CMS) to describe the difference between what he is seeing on the ACEP website (AMA guidelines I believe) and CMS regulations...
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    Authorship in EHR

    In the OP or IP setting, can a physician electronically sign a midlevel's completed note and become the author taking credit for the midlevel's documentation? This is for midlevels not contracted with commercial plans. The physician is the billing provider and documents a supervisory note...
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