1. S

    Question Pulling from Problem List

    I know a diagnosis code can be used if problem is documented on or before the date of service, but how far are we able to go back into the patient's chart for this information?
  2. R


    May a 99172 be used for administering the visual test using only a eye chart and color chart?
  3. L

    Wiki Does it need to specify the DOS?

    I'm confused. I thought each sheet of the chart needs to have a DOS on it, and it needs to specify that the date is the DOS, by stating "DOS", "Date of Service", "Date of encounter".... Basically, it can't be a "lone" date on the chart without the words "DOS", "Date of Service", etc...? Is that...
  4. K

    Use of Acronyms in Chart Notes

    Good Afternoon! I am wondering if anyone out there can help me. I work in a clinic that has a unique range of providers, we have A&D Counselors, Mental Health LCSW's, MD's, PA's, ARNP's, Dental and Pharmacy. Because we have such a range of providers, we have many different styles of notes that...
  5. J

    coding from chart notes

    Our doctors push ICD-10 codes that show up on the chart notes. If he pushes a pain code but the body of the notes state patient has a sprain, etc. I have been coding the sprain or fracture or whatever based on the dictated note not on the code he pushes. ??? Anybody else have issues with this.
  6. L

    Wiki Child Abuse diagnosed as an adult

    Our PA recently saw a 54 year old women who recently discovered that she was sexually abused as a child for approximately two years. The PA coded the note with T74.22XA (Confirmed victim of sexual abuse in childhood, initial encounter) since the diagnosis was new to the patient's chart and to...
  7. S

    Wiki Medical Coding Chart Fees?

    Please advise as to the average fee for coding an individual medical record or chart, internally or as an outside agency. Thanks.
  8. J

    Chart Auditing

    How ofton should you do chart audits, twice a year? How do you select what charts to audit? I am looking for a good starting point. Thanks, Jeannie Hortman CPC