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  1. S

    MDM, diagnosis points

    You would also need to see that each problem is treated or managed in some way. Per 95 guidelines: DG: The initiation of, or changes in, treatment should be documented.Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and...
  2. S

    Pain Management documentation

    Reply to Pain Management documentation There is no issue with typing the radiology report into the note. In the EMR, the radiology reports are pulled into the physician note all the time. The issue would be how you would count this into the E and M. If it is just typed and the provider does...
  3. S

    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...
  4. S

    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...
  5. S

    How to code for "Cognitive Impairments"

    Thank you several years later!
  6. S

    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...
  7. S

    signature for each section of EMR

    Do you have a reference for MEAT? I have not heard of this before
  8. S

    emr hx reviewed by

    I think it is okay to accept because the provider documented in the note that he did review. The MA must have taken the history during initial intake and nothing has changed so it is still in the MA credentials. The provider indicated he/she reviewed, which is acceptable per 95 guidelines
  9. S

    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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    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...
  11. S

    How to code E&M in office if patient not present?

    See the following link from AAP: At the bottom, they explain that the family member may be seen without the patient and the provider may code when time is...
  12. S

    Case #20 Winner, Answer Key, & Rationale

    Thank you for the challenges!! Keep 'em coming!
  13. S

    Ejection Fraction

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

    New Codes 20611, 20606, 20604

    Do you have a reference or website address for this? Thank you
  15. S

    Leveling of E/M without the Marshfield audit tool

    Just wanted to say thank you even though late!! This forum has not been working well for me, surprised I am able to leave a comment now
  16. S

    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...
  17. S

    MDM Work Sheet

    We accept worsening if it is clear from the overall documentation that the problem is worsening. IT would be nice if it was clearly stated in the A and P, but this does not always happen.
  18. S

    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...
  19. S

    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...
  20. S

    Dermatology audit sheet

    I would like a copy as well Thank you
  21. S

    KForce and HIMagine

    I used to work for some people that worked with Kforce part time. They mostly have facility coding jobs.
  22. S

    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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    Performance Status

    I usually see oncologists write this in the exam section, however, I do not know of any exam elements this would count towards. When coding, I typically do not count Performance Status for anything when in the exam. This is because I can usually get a comprehensive exam. If it is mentioned in...
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    Balance Billing Past Timely

    Thank you for the help. I am sorry, I was not clear about the initial billing. The provider billed G0439 for well woman and 99213*25 for shoulder pain. Medicare paid the 99213, but denied G0439 back in August 2013. She was eligible for the service and the provider did obtain eligibility. We...
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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
  27. S

    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
  28. S

    Category III

    Yes, they have to be reported and they are typically denied as they are emerging tech services. Providers are encouraged to submit information to support future coding and use of these emerging tech services. Check your local LCD policy. Here is some info on Noridian LCD :33683: Category III...
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    Preventative Medicine in Oncology Practice

    Thanks again OCD-coder! I did find this info in CPT Assistant: Question: Can a specialist (ie, dermatologist, pulmonologist, etc) report the preventive medicine codes? AMA Comment: The descriptors of the preventive medicine codes (99381-99397) were revised in CPT 2002 to clarify that the...
  30. S

    Comprehensive Examination????

    I see comprehensive: constitutional enmt - thyroid exam psych - alert and orient x 3 cardio resp gi skin neuro
  31. S

    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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    When is cancer consider history of???

    If you look under the V-code guidelines in the ICD9 book, Chapter 18, under "History of" section, it states: personal history codes may be used in conjunction with follow up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or...
  33. S

    Billing H&P before scheduled surgery

    Thank you OCD!!!! It does seem like there should be a way to bill, considering oral surgeons don't typically perform H and Ps.
  34. S

    Billing H&P before scheduled surgery

    So what if the person performing the procedure is an oral surgeon and he/she is performing this procedure at a local hospital. The local hospital requires an H and P for every patient undergoing anesthesia in the hospital for a procedure. The oral surgeon has an internist perform this H and P...
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    We are having a similar issue. Provider wants to bill 91299 (unlisted) but I am seeing this as a category III code which will not be paid (0346T). From the AMA website it looks like it should be reported in addition the correct ultrasound (in the case I am looking at - ultrasound of the liver)...
  36. S

    Nerve block & trigger point injections

    I agree there should be a mod 59 on 20552. I am not sure about the Kenalog, I was only speaking for the local anesthesia (Marcaine)
  37. S

    Nerve block & trigger point injections

    Local anesthesia would be included in the global surgical package The E and M service is also bundled in the surgical package, unless it is a separately identifiable service. For example, patient is seen and examined for a separate diagnosis. I think the CPT codes 64405-50 and 20552 look good.
  38. S

    Borderline Personality Features

    Hi Pam, The notes say "Borderline Personality Features". The code 301.83 is "Borderline Personality Disorder" Thank you
  39. S

    Borderline Personality Features

    Hello Fellow Coding Pros, Does anyone code borderline personality features as 301.83? Or should disorder be specified? Thank you!
  40. S

    How to Bill Psych Test Codes 96101, 96118 and 96116

    Here are guidelines from Supercoder (I have also seen this with WPS Medicare and Noridian) The minimum time you need for reporting one unit of 96101 or 96102 is 31 minutes. If the time spent is 30 minutes or less, you cannot report these codes as CPT? time guidelines for these codes have not...
  41. S

    V70.0 - Our physicians evaluate

    The immunization administration code would capture physician work
  42. S

    Preventative not met

    Thank you for your response Debra. I have heard the concern about the patient copay however, from a documentation perspective the visit does not meet preventive requirements. Upon audit, it would have to be repaid. The only option left would be a no charge, but the physician is having a face...
  43. S

    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...
  44. S

    Date of Service

    Physician outpatient clinic charges
  45. S

    99205 & 90792 ?

    No according to CCI, no modifier allowed
  46. S

    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...
  47. S

    Opinions please - shared visits

    Thank you for your response OCD coder. They are under WPS Medicare and I did just find some better documentation indicating that seen and examined is not sufficient. Which is great to finally find!
  48. S

    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 -...