e/m documentation

  1. KStaten

    Wiki 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...
  2. M

    Wiki How do I know whether or not to start looking for an E/M on a documentation?

    Here's my example for practice. Date of service: 13 Jan 2020 Chief complaint CC: chronic right shoulder pain HPI Pt is a 24 y/o male who is in the orthopedic clinic today 13 Jan 2020 for right shoulder steroid injection. He had been evaluated by Dr. XYZ for possible impingement syndrome and he...
  3. A

    Wiki How is this should be coded? (OB/GYN OUTPATIENT)

    Hi guys! Can you please help me to code this ob encounter? Scenario: An established patient visited the clinic for her initial antenatal care. She is currently 15 weeks pregnant (G2,P1) with previous cesarean section due to breech presentation. This is a spontaneous pregnancy. Patient has...
  4. M

    Wiki Necessities for inpatient initial consult

    When coding for 99221-99223, I have seen mixed reviews on what is acceptable for a complete ROS, some state that if you document the positive systems with associated symptoms, and write "all other systems reviewed and negative" it is acceptable for a 99222 or 99223 (with all other requirements...
  5. A

    Wiki established patient visits- can physician transcribe note prior to visit????

    I work for a billing company, and with one of our newer clients some physicians are transcribing the office note the day prior to the visit and then signing it after the visit. Is this acceptable?
  6. A

    Wiki E/m + 10060

    Am I allowed to bill a 99213 + 10060 or is the e/m bundled into the procedure? Where can I find proper documentation to present to my providers? thx!
  7. M

    Wiki Physician Review Conference

    When a physician is doing a review conference; meaning they are telling the patient the results of their skin test or any other test they may have done, what information needs to be included on the encounter in order for it to qualify for an E/M service code?
  8. E

    Wiki PFSH Documentation Question

    Hello out there! I'm trying to find information on proper documentation for past, family, and social history. I know that "unremarkable" and "reviewed" are unacceptable, but I've run into this one lately: "No significant family history pertinent to this hospitalization." To me, that seems like...
  9. 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 . . . ?
  10. R

    Wiki can coder select E/M code for doc?

    Does anyone know if there are any rules or guidelines that say the physician has to be the one to select the E/M code. I am wondering if it is legal for a certified coder who works in a physicians office to select the E/M code for the doctor based on the doctors documentation instead of the...
  11. K

    Wiki Diagnosis billing

    On the exam Doctor write notes skin abnormal (Ex:nevus.hyperpigmentation, heart : Abnormal heart murmur,etc.,) Medical decision making he refers the patient to see specialty doctor(derm/Cardi) or write notes follow-up next visit for any improvement can I code (ICD9 Dx) and bill to the...