1. H

    Wiki Spousal abuse coding. When is it considered confirmed or suspected?

    Hello! I bill for Inpatient hospital visits for teaching physicians. I don't normally see abuse charges come in so I am a little bit confused about how I should code this patient's situation. The patient came in with heroin overdose. When asked the, patient stated his wife gave him the...
  2. H

    Wiki Drug USE coding

    Drug USE coding [when not listed as Dependence or Abuse] Hello, I am fairly new to coding and I am seeing alot of my Doctors stating Drug use in their reports.(usually through the patient saying they use it or the presence of the drug in blood/urine screenings and they are not a part of their...
  3. A

    Wiki Hipaa and CPS

    If you see a possible example of child abuse/endangerment, and you DO NOT see that the dr. has reported it, can we as coders report? Or is that against HIPAA? Can you just say that you think there might be child endangerment, but not any of the circumstances behind it? Or is just giving a...
  4. A

    Wiki Alcohol abuse/anxiety disorder

    I have a case where the patient has alcohol abuse, PTSD, anxiety disorder, among others. My question is, would I link the alcohol abuse with these conditions such as anxiety disorder? They are not linked anywhere in the documentation but by the new guidelines of "with" they would be linked...
  5. A

    Wiki HELP!!! Billing E/M without finishing note

    Help! I need answers or at least confirmation! I recently started a new position in a new company. The one physician owner is requesting that we bill out his E/M services without him signing off on the note. I have told him that I absolutely refused, due to guidelines. However, it was brought...
  6. K

    Wiki polypharmacy abuse

    Is there a way to code polypharmacy abuse without knowing the exact drugs used? It is a secondary code to suicidal ideation.
  7. N

    Wiki Substance abuse

    If provider documents substance abuse in full remission, how should i code it? there is no remission code for abuse. would I just not code it because it is inactive?
  8. C

    Wiki Abuse Codes

    Hello, I am mental not able to handle the abuse codes. For some reason they are driving me mad! I can't make heads or tails what I am sure is a very simple explanation. I am hoping someone has a link or a tip that will help me. Is this correct? Abuse VICTIM CONFIRMED - T74 Abuse VICTIM...
  9. N

    Wiki Dilema: EMR templates documents things that were not done

    I am facing a ethical dilema here at work. The family physicians use a template for their office visits. The templates are pre-loaded with ROS and exam documentation, and it is up to the physician to edit such. The problem? The physicians do NOT edit. The office visit documentation for an...