e/m audit

  1. J

    Wiki Independent Historian: Spouse

    I'm currently reviewing a case where a new patient is downplaying the severity of his current issue, infection of big toe, and denying any other current health issues to the provider. His wife is documented as stating that the patient has diabetes and high blood pressure, has had several cases...
  2. daedolos

    Wiki 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...
  3. B

    Wiki Audting Practice

    Hi! I am studying for my CPMA and I plan on sitting for the exam in October. Does anyone know of any other resources that offer auditing practice using the CMS guidelines? I would really like to practice more charts before i sit for the exam since this is a large part of the exam. Thank you...
  4. D

    Wiki Treament options or number of diagnosis

    Just for clarification, if a patient with no symptoms presents for a consult for screening colonoscopy, would this be scored as self-limited or minor, or new problem additional work-up planned. There is some disagreement in our office about this. Or if anyone could point me to a source to be...
  5. M

    Wiki Surgical/E&M codes

    Is it ok to send both E/M and surgical service together if no separate identifiable non-surgical service is given at the time of service? Is it per payer contract, which can allows both together(E/M and Surgical codes) or E/M code can supersede Surgical code even though it is truly surgical...
  6. E

    Wiki Meet and greet?

    Hi there. Wanted to know the opinions of some of my peers about the following chart note and how to code. What are your thoughts? HPI: Establish Care. No other concern today. Has had flu shot. Pt is here to establish care today. She is transferring care from another of our clinics. She denies...
  7. A

    Wiki medical necessity

    Medical necessity is the overarching criterion in billing- I guess per Medicare, Medical Necessity is “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.” I think this also have plenty of meanings-...
  8. C

    Wiki Policy for Selecting E/M Level

    Can an outpatient physician's clinic implement a policy that the coder doesn't change the e/m level because they want to establish a written policy that the physician is responsible for the e/m selection? I would think the coder should determine e/m level since they are checking the...
  9. N

    Wiki In house E/M audit

    We are conducting in house E/M audits of our family practice docs. If any of you fellow coders have any available material to share with us that would be helpful to our "wet behind the ears" employees, it would be appreciated. Sincerely, Nancy