1. KStaten

    Documentation for Number of Views for X-Ray Interpretations

    Hello Everyone! :) I need confirmation on documentation for x-rays, please. Scenario: A physician orders and reviews knee x-rays in his/her office. The orders that appear in the note state the number of views. Does the physician ALSO have to state the number (or specific name/type) of views...
  2. D

    Question Diagnosis specificity

    May a coder use the exam for specificity without having to task the provider? The provider states they documented location in the exam and does not need to re-address the location in the assessment? The coder would like the location listed under the assessment. Very interested in the response...
  3. KStaten

    Documentation Requirements for Components of E/M

    Hello Everyone! With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends...
  4. KStaten

    Question What are the Documentation Requirements for Viscosupplementation (Monovisc, Euflexxa, Durolane, etc)?

    Hello Everyone, I am searching for the documentation requirements for viscosupplementation injections, such as Monovisc and would appreciate if someone could point me in the right direction. As these are administered in pre-measured syringes, I have (on one hand) been advised that the dosage...
  5. N

    Excision using post op defect size

    We are having debate in office on documentation & measuring lesions. They do not want to use verbiage of lesion diameter or margins or total excised diameter in the documentation..only what is in the example below: EXCISION: of Bcc left cheek. Preop .8 cm by .6cm Post op defect size 1.0 x .9...
  6. KStaten

    Answer Coding / Billing Audio-Only Telehealth Visits

    Hello Everyone! :) Here's my silly question for the day. (Brace yourselves, as I am sure more are to come. ;) ) As I have interpreted from articles, the accepted Telehealth services have been expanded to include audio-only telephone calls, as well. (Yay!) Now this is the part where I am...
  7. KStaten

    Question What Designates an "Active Involvement" in Plan of Care?

    Hello Everyone! 🙂 According to what I have read (in regards to incident-to billing), in order for a patient to be seen by the PA and still be billed under the doctor, the doctor must do the following: 1) Initiate the treatment 2) Continue to be "actively involved" in the patient's case/ plan...
  8. KStaten

    Question Who Has Documentation Permissions per Medicare Guidelines?

    Hello Everyone! :) I am trying to put a table together to describe components of a medical document for a typical outpatient setting office visit and list who (per Medicare guidelines) has permission to document each one. In other words, in order to correctly bill under the physician, what...
  9. P

    Intra-operative monitoring technical component

    Hello, I work for a small IPA and we are trying to figure out what is correct for the technical component of IOM. I have been denying them because I assumed the technical component was payable to the facility, but I am not sure that is correct, because there is a tech and the neurologist. Does...
  10. M

    Question Which part of the documentation can Coders use to code from?

    I'm really sorry if this has been posted before but I couldn't find anything when I searched the forum (probably because I couldn't figure out how to phrase it correctly.) Which part(s) of the documentation can coders pull dx codes from? Say, the provider only listed BMI or Obesity on the...
  11. C

    Question OB global documentation needed?

    I am very new to OBGYN and trying to audit the OBGYN dept as a whole has me asking more questions before I can even begin. Our OBGYN dept has asked me to do an in-depth audit of their department... including more than what I typically audit; office visits, hospital services, OB triage...
  12. K

    Question When is a pre-built Template taking it too far?

    I have a provider that has a pre-formatted template that looks like the entire note is complete with already generated diagnoses and labs/procedures. Absolutely nothing prompts entry by the provider and it's a complete note with HPI, ROS, Exam and A/P. This is a data integrity issue but I'm not...
  13. H

    Question Locus and telemedicine

    Does anyone have any experience or knowledge on using off site locums tenens provider to bill telemedicine and what requirements I might need to follow or make sure are enforced? Is an offsite locums different than onsite?
  14. M

    Question ICD-10 codes in progress note vs codes on claim

    The software that we use allows the provider to add diagnosis codes to a section of the progress note, however a lot of the time the codes are not correct (eg. documentation says "Diabetes Type I", but provider lists code for DM type II). My supervisor insists that I need to contact the provider...
  15. C

    Rhizotomy or neurotomy documentation

    Hello, So I know a rhizotomies and neurotomies are basically RFAs, so we would use cpt codes 64633-64636. However, are the the documentation requirements the same? Meaning do we need temp and duration documented in the op notes for a rhizotomy or neurotomy?
  16. A


    I work for a private practice who has refused to provide proper documentation for many years. I am really pushing them to start documenting, but I am getting major push back. I am asking for some help as they will only look at payer guidelines, and nothing else. I need some resources or some...
  17. S

    How do I determine E/M level for prenatal visits for Texas Medicaid

    Texas requires us to bill "the most appropriate level E/M" for prenatal visits. How do I determine the level of E/M though? Do I use the 3 key components (history, exam and MDM)? My company audits on 1997 guidelines, but with an prenatal visit, there is no "real" physical exam, other than...
  18. N

    Interpolation Flap--documentation requirements. Is this enough

    Hello, Wondering about this closure documentation. This scenario is for MOHS, for BCC on the right helix, with closure same day, this is all on one note. At first, all it said was "Closure, Interpolation repair." Then it was corrected to say the following: "Because of the size, location, and...
  19. G

    Toenail excision

    What is the proper documentation that needs to be done by the provider to be able to charge 11750 excision of nail and nail matrix partial or complete, for permanent removal? As my provider has a template that he follows for example: consent was signed: yes complications discussed: yes timed...
  20. baroquecoder

    Physician orders for laboratory tests

    Clinic is stating they placed an order for urinalysis 'digitally' so they don't need to submit documentation for the UA. I'm unable to code it as there is no diagnosis or intent for the procedure indicated. What are the documentation requirements for a physician ordered laboratory test...
  21. daedolos

    E/M query

    I just recently took a coding exam for a prospective employer and one of the questions were as follows: The level of E/M is based on: A) Documentation B) Key components C) Contributing factors D) All of the above I chose the wrong answer of A. Any thoughts? I read up on E/M principles and...
  22. D

    Dx in A&P

    Good Morning All, When we have a diagnosis that is documented in the A&P only the education team in my office is split on whether or not this is "dingable". I haven't been able to find any guidelines that says ya or nay on this topic. Any help with included resources/guidelines would help us...
  23. C

    92557 Comprehensive audiometry threshold evaluation and speech recognition

    Hello, I have a couple of questions regarding CPT 92557. My understanding is that the elements of CPT 92557 are: Air and bone on the RT and LT Speech recognition SRT on the RT and LT WR on the RT and the LT Do both intensity and masking need to be completed for speech recognition to...
  24. C

    Cholelithiasis with chronic cholecystitis with obstruction vs no obstruction

    Hey. I'm confused about when the documentation means that there was an obstruction with the cholelithiasis and cholecystitis. What kinds of things do you usually look for in the documentation when an obstruction is included with that? :confused:
  25. M


    My provider has hired someone to take her handwritten notes and enter them into the EHR. This employee is not in the exam room and is completing the note after the visit. This is a family practice provider. I am the biller/coder. Does anyone know if this is acceptable or the guidelines for this...
  26. C

    TCM Documentation

    I am questioning the necessary documentation to bill TCM visits. It is stated that the complexity of medical decision making (moderate or high) must be documented in medical record. Does the provider have to specifically state this in the note or is the CPT Code enough? Any input would be...
  27. B

    Advanced Maternal Age

    Hello, If a patient is 35 years of age but the provider doesn't pull in the AMA diagnosis and doesn't document the advanced age as a concern can you still list the diagnosis because the patient is age 35 or older? Or do you leave it off because the provider hasn't documented it. Thanks in...
  28. K

    Documentation in Medical Record

    Wanted to get clarification on requirements in the Medical Record. My team has been instructed to bill claims missing results or interpretations from the Medical Record as long as it is located somewhere else in the Health Record. However, we don't have access to verify these other locations and...
  29. M

    Documentation help

    I have a denial for insufficient documentation for a Arthroscopic decompression subacromial space w/partial acromioplasty (29826- RT) it was billed with a 29824-51-RT and a 29827-RT that both paid correctly. Being new to ortho, I have lots to learn. (I have scheduled a boot camp) This is...
  30. T

    G0446 Intensive Behavioral Therapy Cardiovascular Disease Documentation Requirements

    Good Afternoon, Would anyone have a good resource for documentation requirements on G0446 Intensive Behavioral Therapy for Cardiovascular Disease. Is there a commercial code for this. Thank you in advance. Tammie Womack, MBS, CPC
  31. B

    Coding from HPI for LTC

    Hello All, I work in LTC and I got a notification from one of my MDS nurses that they had added a dx of Dementia for a resident, but I did not have it on my diagnosis sheet for that particular resident. I went through all the documentation and could not find a dx or dx code of Dementia for said...
  32. A

    ? Exam

    Hello... I am just reaching out for a little help regarding an Exam. 2 Coders are not agreeing on level and documentation {imagine that!} After first looking at this exam I feel it might be detailed or Expanded problem focused, but not a Comprehensive. Please coders give input... General...
  33. C

    HIPAA timeframe for completing documentation for an encounter

    This may be an unusual question, but I'm hoping someone out there can guide me to the answer. The provider at my clinic is from a much older generation. As such, he has been rather slow to embrace EMR and relies heavily on his handwritten notes when examining patients. After the encounter, the...
  34. K

    documentation of ulcer sizes with debridement

    Is there any guidelines stating if an ulcer size needs to be documented before or after debridement? My General Surgery office documents size prior to debridement but a coworkers Plastic Surgeon office documents size after debridement. Or should they both be documenting before and after sizes...
  35. N

    lesion removal documentation

    Medicare requested prepayment documentation for lesion removal. (11642 11422 & 11441) I sent they operative report which showed lesion size in the heading of the op report. Procedures: 1. Excision of left brow carcinoma in situ (1.5 cm) 2. Left lateral canthus skin lesion excision (0.6 cm) 3...
  36. M

    Doctor in the suite documentation

    Our nurse practitioners are seeing patients for more than one doctor during the day. Does it have to be the NP to document which physician is in the suite? Can the ancillary staff documents that the patients doctor is in the suite and available for consultation and the NP review the comment...
  37. S

    Critical Care documenting by ED physician

    With Critical Care codes being time based can the provider document Critical Care time and that plus the medical necessity evidenced by the diagnosis be enough to constitute Critical Care? Is the fact that they ordered intervention (labs/tests/intubation/etc) enough to show the intervention or...
  38. L

    Physician not reporting critical care time

    I have a problem with a physician in our ED not reporting his critical care time so the facility can report it for the revenue. I am trying to find documentation on CMS or any other supporting site to take with me to Quality Assurance to let them know manipulating documentation for maximum...
  39. J

    CPT code 31624

    Help! New to pulmonary coding. In search of written documentation that when performing a lavage (BAL) that documentation needs to state instillation and return. Does anyone have guidelines or documentation, preferably from CMS stating the requirements? Thank you!
  40. S

    PLEASE HELP - Pre and post debridement measurements with callus

    I have providers in a podiatry clinic who are documenting 0 x 0 x 0 sq cm as the pre-debridement measurements when a callus is overlying an ulcer and then they document the size of the underlying ulcer post-debridement. They state that they cannot measure the wound before the debridement, since...
  41. L

    How do you handle this in your office?

    How does your office handle it when they receive incomplete charts from providers? Some examples: The start and/or stop time is not on the chart. There is no diagnosis on the chart. There are no anesthesia providers listed on the chart. If the above information is not on the actual chart...
  42. K

    What constitutes a patients medical record?

    At the clinic where I work when vaccines are given they are recorded online in a state registry but nowhere within our EMR. I have been told that the state registry is a part of the patients medical record and therefore that is sufficient documentation. But since we don't maintain that registry...
  43. 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.
  44. K

    Vaccine Documentaion Question

    I have recently started a new job at a clinic in Washington state. At this clinic they do not document any of the shots they give to children because they document them online at the Washington state immunization registry. They say that is sufficient documentation to bill out the shots because...
  45. C

    checklist for audits

    Hello, Does anyone have a sample checklist for when payers are requesting charts for an audit? For example I'm looking for the following documents: chart note, procedure note, consult letter, etc? I want to be sure we have all needed documents per chart. Thanks, Camille Waterhouse, CPC
  46. C

    Consult documentation requirements

    I am looking for clarification. A consultation requires the written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or appropriate source. The consultant's...
  47. C

    Consult documentation requirements

    I am looking for clarification. A consultation requires the written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or appropriate source. The consultant's...
  48. D

    General Chart Review Question

    Hello all. I am a new AAPC member working on my CRC certification. I work for a start up health plan in NYC and we are working on conducting our first round of chart reviews for risk adjustment. If a health plan has medical records and identifies discrepancies in their HCCs (assuming the...
  49. C

    Chart Auditing-Compliance Commitee Otolaryngology

    I am interested is establishing a process/committee to audit Otolaryngology physician charts internally. We want to verify that medical necessity documentation is being met for procedures and that the documentation supports the CPT's billed. Has anyone set up an internal auditing process or...
  50. S

    documentation requirements for vaccines(flu)

    Hi All, Hopefully someone will be able to answer my question. What documentation is required for billing/reimbursement for a flu vaccination? Saundra