documentation

  1. L

    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...
  2. K

    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...
  3. M

    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...
  4. B

    Nutritional Therapy

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

    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...
  6. S

    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...
  7. A

    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...
  8. C

    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...
  9. B

    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...
  10. D

    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...
  11. P

    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?
  12. T

    coding placenta previa

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

    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...
  14. G

    Anemia sequencing

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

    96372 following anesthesia

    Anesthesia Resources What are your most reliable resources for information when you have coding questions?
  16. 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...
  17. S

    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 . . . ?
  18. S

    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 . . . ?
  19. R

    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...
  20. K

    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?
  21. V

    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...
  22. N

    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...
  23. alisonbee

    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...
  24. L

    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...
  25. S

    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?
  26. K

    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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