documentation

  1. N

    Wiki 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...
    • NPSDEB
    • Thread
    • 11422 11441 11642 documentation lesion removal
    • Replies: 1
    • Forum: Dermatology
  2. M

    Wiki 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...
    • MWaters
    • Thread
    • billing and coding documentation incident to
    • Replies: 0
    • Forum: E/M
  3. S

    Wiki 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...
    • stephaniehughes
    • Thread
    • critical care documentation e/m
    • Replies: 2
    • Forum: E/M
  4. L

    Wiki 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...
  5. J

    Wiki 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!
  6. S

    Wiki 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...
  7. L

    Wiki 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...
  8. K

    Wiki 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...
  9. K

    Wiki 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.
  10. K

    Wiki 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...
  11. C

    Wiki 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
  12. C

    Wiki 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...
  13. C

    Wiki 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...
  14. D

    Wiki 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...
  15. S

    Wiki 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
  16. C

    Wiki Interphalangeal Arthroplasty?

    Hi All, I'm stuck. One of our docs is adamant that his operative report documents something that none of our coders can find. His heading states "DeVries arthroplasty, right second, third, and fourth proximal interphalangeal joints" (bolded below) We could not find it to be documented in the...
  17. H

    Wiki Documentation requirements when billing TC portion only of radiology exams

    Can anyone direct me to established documentation requirements when billing the technical portion only of a radiology exam? I am working with several clinics who perform x-rays in the office that are then sent out to be read. The images are not housed in the EMR and coders are having a...
  18. B

    Wiki Coding Question- Foreign Body Left Finger

    Hello All! I had an op report come through that I'm struggling with whether or not there is enough documentation to bill anything. What are your thoughts? [B]Pre-Op Diagnosis: Foreign body left ring finger Post-Op Diagnosis: Normal Exam Description of Procedure: Patient taken to operative...
  19. T

    Wiki Physician needs proof

    One of the physicains I code for does not think she needs to add the diagnosis to the assessment portion of the EMR. She likes to use the special history and put everything in there. She feels that to put the diagnosis in the assessment is doing double documentation and she does not like to do...
  20. L

    Wiki correcting documentation before claim submitted

    I code hospital billing and I have a provider who has an intern following him, recently he has allowed the student to document handwritten progress notes and he signs over them correcting/adding/ inputting his own MDM, however the note doesn't have anywhere documented that the intern wrote it...
  21. K

    Wiki Nephrology - coding inpatient

    I am new to coding inpatient hemodialysis for physicians and I have a question about documentation. When the doctor sees the patient while on dialysis, do they have to actually document, "patient seen on dialysis"? Also if they are on CRRT, is it assumed that they were seen while on dialysis...
  22. M

    Wiki Documentation of Premature Delivery

    I have a question about something I was told about coding deliveries. I was told that unless the doctor specifically documents the phrase "premature delivery" in his note, that we can't use the diagnosis of premature delivery. For example, in the op note or delivery note, our hospital uses a...
    • mchllshrms
    • Thread
    • documentation ob coding
    • Replies: 0
    • Forum: OB/GYN
  23. B

    Wiki Nutritional Therapy

    Is it correct to bill cpt 97803 w/10 units according to documentation? Since it states each 15 minutes? thank you.
  24. K

    Wiki Documentation support an arthroscopic Labral repair?

    Help please as shoulders can still confuse me...... Do you feel this documentation support billing a 29806 for an arthroscopic Labral repair? "The labrum was not intact anteriorly.......I freed up the anterior labrum. The inferior root was intact. I placed 2 Biomet juggernot anchors along the...
    • klbecker
    • Thread
    • anterior documentation intact labrum repair
    • Replies: 1
    • Forum: Orthopaedics
  25. S

    Wiki Initial or subsequent MI?

    Hi, I would like to ask for your input regarding coding initial or subsequent MI. I have a patient who was admitted due to SOB. Patient had an NSTEMI 2 weeks ago. Later during the admission, patient became bradycardic and reported chest tightness. A code was called . Monitor showed...
  26. A

    Wiki Cancelled procedure documentation

    There seems to be some debate. In an outpatient/day surgery setting, does a provider need to document the reason why a procedure was cancelled and sign off on it? Or is it sufficient for the nurse to write the reason why in a progress note/nurse note. Specifically if its cancelled due to pt...
  27. C

    Wiki Fracture care documentation

    My physician diagnosed a fracture however all he indicated on his report that the patient is to wear a locking knee hinged brace at all times is required and he wants to bill fracture care. Can anyone guide me to more documentation so that I can educate my provider? I know the AAOS is a huge...
  28. B

    Wiki Exam documentation - I know that VS can be counted as constitutional

    Hello everyone, I code E/M for ED providers, and I have a question about exam documentation. Occasionally, for whatever reason, the exam portion of our notes will be blank, with the exception of the vital signs. I know that VS can be counted as constitutional, but is that a billable service...
    • bforr
    • Thread
    • dental documentation e/m exam guidelines
    • Replies: 2
    • Forum: E/M
  29. D

    Wiki Injections and PA or Dr to be rendering

    If Dr. A sees a patient and does the H&P and X-rays and all of the office visit portion and leaves the room then his credentialed Physician Assistant goes in alone and gives the patient an injection in her knee. Dr A’s documentation is for the OV portion and PA’s documentation is for the...
    • DAV829
    • Thread
    • billed documentation injection patient portion
    • Replies: 1
    • Forum: Orthopaedics
  30. P

    Wiki Documentation Requirements to bill professional component for Cardiac Device Eval

    Does anyone know where I can find what documentation is required to support the billing of the professional component of a cardiac device evaluation?
  31. T

    Wiki coding placenta previa

    If the doctor only states in the documentation placenta previa, should placenta previa with hemorrhage be coded?
  32. L

    Wiki Documentation

    Fellow Anesthesia Coders, do you get all you need in your documentation to accurately code for ICD-10? There's been a suggestion in my office to code from the facilities' face sheets. It's been my understanding that we are to only code from our providers' documentation. What do you do when...
    • LisaAlonso23
    • Thread
    • anesthesia code documentation facilities office
    • Replies: 0
    • Forum: Anesthesia
  33. G

    Wiki Anemia sequencing

    In what order would dx be sequenced for a patient w/malignancy and anemia. How should should documentation read?
  34. L

    Wiki 96372 following anesthesia

    Anesthesia Resources What are your most reliable resources for information when you have coding questions?
  35. C

    Wiki New CPT code 69209

    I'm looking for where i can find documentation on new CPT code 69209 and if this new code has the requirement of being done by a provider? I know that cpt code 69210 although not included in the actual description of the code, in order to bill for this service, it must be provided by doctor or...
  36. S

    Wiki What is your go to refrence that is not the DG's or google?

    I know there are lot of books that provide guidance for documentation and auditing of E/M services. I'm curious which one book is your go to . . . ?
  37. S

    Wiki What is your go to refrence that is not the DG's or google

    I know there are lot of books that provide guidance for documentation of E/M services. I'm curious which one book is your go to . . . ?
    • stephanie7480
    • Thread
    • documentation e/m e/m documentation provide refrence
    • Replies: 0
    • Forum: E/M
  38. R

    Wiki 99211 with lab tests

    Hello, I have an office that wants to bill a 99211 with the MA or RN assisting a patient with the H Pylori test in their clinic. I am stating no since the patient can do the test themselves and there is no documentation for an E&M visit but meeting some resistance. Any coders out there know...
  39. K

    Wiki 77080 documentation

    When a provider has the Dexa Scan done in their office and they bill without a TC or 26 modifier are they required to have the scan AND interpretation report or is the scan enough documentation?
  40. V

    Wiki Training a Doc on E&M Doc.

    I've been working on coding & documentation with my physician for more than a year now, but haven't seen much change/improvement in understanding or execution. There's some implied pressure to use his choice of E&M codes, in spite of documentation deficiencies (we are experiencing decreased...
    • Viper66
    • Thread
    • documentation training
    • Replies: 1
    • Forum: E/M
  41. 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...
  42. alisonbee

    Wiki Laceration Documentation

    This note is from the Physical Exam: UPPER EXTREMITY More prox one is 5 cm in length, wide and gaping through fatty tissue. Goes across vertical strips of his tattoo. There are mult pieces of metal as well as pieces of tattoo ink within lac. The more distal lac is 2 cm in length, not as deep...
  43. L

    Wiki Physiacian Documentation

    Please help Does anyone know of a resource that shows when it is ok to ask a physician to add documentation to a chart and when it is not because it may be mistaken as trying to get more revenue for the visit (upcoding). We have not been able to find anything in writting. Does anyone have...
  44. S

    Wiki DRG coding in an ASC??

    :confused: Hello, I was told today that you are supposed to use DRG codes when you bill for work comp procedures in an ASC setting. I have never heard of that before. Does any one know if that is the case. If not, where could I get some documentation to back myself up?
  45. K

    Wiki BMI index measurements

    Good afternoon, I have a question about BMI measurements, and how they are obtained. I thought the way to calculate is by mathematics. I cannot find a procedure code that this represents. I have an office that wants to use procedure code 93720 as a way of determining BMI. I cannot find any...
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