coding and documentation

  1. K

    HPI element

    Good afternoon I have a question in regards to HPI elements for the following example and would appreciate any advise and insight Established Patient visit Reason for visit - HIV Followup Last seen 1.2.2019 CD4 660/30% ,viral load 21 on current meds Dx HIV 2011 . Risk Factor Heterosexual...
  2. V

    GI Op Reports Audit Tool

    Hi, Does anyone have an Endoscopy and/or Colonoscopy Audit tool they are willing to share:
  3. A

    Resection of carpal trapezium w/internal brace stabilization for thumb base arthritis

    Hi all, I would like an expert opinion on which CPT code is most appropriate for what looks like a "suspension version" of a CMC arthroplasty. Per op report: "...A marked amount of arthritis at the trapezial carpometacarpal joint was identified. The trapezium was osteotomized in 3 places...
  4. L

    Oct 1 2017 change to L57.0 code-needs additional code??? HELP

    Hi we are in Pennsylvania we regularly treat and bill L57.0 code under the 17000/17003/17004... I saw in the proposed changes and deletions upcoming is one that states that you need to use an additional code to identify the source of the ultraviolet radiation? We have never had to do that ever...
  5. C

    code corrections and modifiers

    Ultimately the physician is responsible for codes, modifiers and diagnosis that are submitted on a claim. I am looking for information on what a certified coder can do vs. a non certified medical biller. Can a medical biller who is not certified add a modifier to a claim or must this be...
  6. K

    vaccine counseling documentation

    Can anyone tell me if this documentation is sufficient for billing 90460 imm admin w/ counseling? HIB vaccine 90648 Counseling by: providers name MD It doesn't seem sufficient to me but the people I work with feel it is.
  7. C

    Documentation resources

    I am trying to provide documentation resources to my providers, showing them what needs to be included in operative/procedure reports. I have researched, but can only seem to find info on medical necessity, ordering of supplies, home health, etc. Does anyone have good articles on what needs to...
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