1. L

    Question UTI's/Hx of UTI's and Chronic Cystitis?

    I'm look for some guidance here regarding documentation for the diagnoses in the subject line. My providers tend to code N30.20 - other chronic cystitis w/o hematuria when documentation states something along the line of: pt seen in consultation for recurrent UTI's, they state a few of the...
  2. A

    Question Releasing charges without first reviewing the note to support the E&M level chosen?

    I have a couple questions and would like the opinion of other coders/clinics. How many practices are releasing charges without first reviewing the note to make sure the E&M level chosen by the provider matches the documentation? How many coders are letting the Dr's choose the level of E&M and...

    New Patient Documentation

    Should the documentation of an office note indicate if a patient is new? My established providers document if the patient is new to group in either the Chief Complaint or HPI. ie: Patient present as a new patient for refills on blood pressure medicine but my newer providers do not. I thought I...
  4. M

    Help with documentation

    We have a new medical provider who does not state the diagnosis or symptoms in his notes. The diagnosis codes are selected by the provider from a drop down list on another page, but not stated in the documentation portion of the note. My job is to determine the level of E/M and I'm worried about...
  5. K

    Question Coder liability in timely documentation

    Does anyone have insight or resources in relation to the liability that falls on a coder when a provider submits documentation weeks/months after a visit occurred to be coded? Conversation came up that I could potentially start receiving documentation from however long ago a provider decides to...
  6. S

    Question Is documentation of procedures in a separate note from E/M necessary?

    I work for an EHR vendor and we've had some ophthalmology clients complain that payer audits have dinged them for having minor procedures, such as injections, documented within the same encounter as an office visit. According to these clients, the audit results state the procedure has to be...
  7. 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?
  8. T

    Question Required documentation for billable services - Nurse Visits

    Hello, I am looking for guidance on required documentation. Are SOAP notes and/or EHR master notes required for lab only or vaccine only visits (not with a provider)? Examples: Nurses Visit: Vaccine only, Nurses Visit: Covid vaccine only, Nurses Visit: Lab work (G0328, 82962, etc.) I appreciate...
  9. M

    Question Radiology contrast documentation

    I have a question regarding documentation for contrast billing. Is it ok that the report states gadolinium for the injection, or does it specifically have to state Gadavist (the brand) in the report in order to have proper documentation for billing the contrast? Or is it sufficient enough that...
  10. K

    Documentation Question for Comprehensive Exam

    Assuming all 12 elements of an annual comprehensive examination have been completed with an associated medical diagnosis, such as cataracts, does completing a refraction or updating prescription glasses qualify as implementing treatment and does it justify billing 92014? Also, assuming all 12...
  11. KStaten

    Injection Template Documentation Guidelines

    It has been to my understanding that the provider is responsible for documenting the procedure, exam, and plan (unless he/she is assisted by a scribe). IF a provider decides to start using a template (such as for routine joint injections), which has drop-down menus to enter the correct...
  12. J

    Question Mode and Means of arrival not captured - can I send it through?

    I have an ER visit from July 26 where the nursing staff did not document the mode and means of arrival for the patient. We have always sent it back to the nurse as that is a facility requirement to have it documented. The nurse is no longer here. Normally they are able to look in the dashboard...
  13. G

    E/M level

    Our surgeon wants a 99205/99215 for these visits. We cannot seem to find the documentation supporting these levels. Wondering if maybe we are missing something? We are also asking so we can have information from somewhere besides us (coders) to support our decision when trying to educate the...
  14. 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...
  15. 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...
  16. 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...
  17. 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...
  18. 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...
  19. 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...
  20. 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...
  21. 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...
  22. 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...
  23. 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...
  24. 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...
  25. 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?
  26. 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...
  27. 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?
  28. 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...
  29. 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...
  30. S

    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...
  31. 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...
  32. 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...
  33. 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...
  34. 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...
  35. 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:
  36. 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...
  37. 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...
  38. 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...
  39. 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...
  40. 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...
  41. 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
  42. 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...
  43. 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...
  44. 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...
  45. 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...
  46. 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...
  47. 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...
  48. 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...
  49. 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...
  50. 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!