documented

  1. C

    Preventive physical exams, Medicare patient

    Hi everyone! Before I continue I want to clarify that this has absolutely nothing to do with the Medicare AWV. This is a hands on, head to toe, physical exam. A patient comes in every year and has the same thing, clearly documented, coded 99396 through age 64. Now this patient is on Medicare...
  2. A

    AWV Element Questions... need help please.

    Our practice is new to doing AWVs and I want to make sure we are documenting all the requirements appropriately. I've been reviewing the CMS document for AWVs: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf, and I have a...
  3. J

    Cardiology codes for vein mapping?

    Does anyone know a specific code for lower extremity vein mapping? This is the first time I have seen that documented by my cardiology group.
  4. C

    Physicians Not Specific Enough

    Hi Everyone, first time posting, so hopefully this is the proper thread! I work for a company that does billing, coding and collections for outpatient surgery centers (ASC). We are increasingly running into problems where our coding of operative reports does not match up with how the surgeon's...
  5. M

    Coding/Billing for Diagnoses

    My provider wants us to use co-morbid conditions when proving medical necessity for urine drug testing (we work in Pain Management). However, these co-morbid conditions are not always noted on the note for that visit. I am hesitant to use codes that the doctor hasn't documented in the note...
  6. N

    establishing a patient

    how do you code an encounter when the patient came in to establish care. No problems are documented. Basically it a meet and greet thing..
  7. H

    Can BMI code Z68.xx be billed with documentation alone?

    Hello, The title pretty much asks the question. BMI is documented in the vitals, but it is not documented in A/P portion of the progress notes. Can the BMI still be billed? Thanks in advance.
  8. J

    Time in E/M coding

    I went to a conference recently where I was told in an E/M panel Q&A that a statement after the Discussion portion of the note stating "31 minutes of the 60 minute visit spent in coordination and counseling of care" was not adequate to code on the basis of time, even if the Discussion documented...
  9. T

    Critical Care Codes

    To be able to use critical care codes the time must be documented specifically by the physician, correct? This is for a pediatric patient who was transferred to another facility after being worked on here for a few hours. The critical care time is not documented by the physician. So I would just...
  10. C

    Preventative vs established

    Scenario established visit- documented as a CPX. Several established chronic problems listed-- ALL stable. NO chief complaint, but each chronic problem addressed (some documented as followed by another physician). No HPI-- as the problems are mostly current but chronic in terms of years. Good...
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