e/m leveling

  1. N

    Question HPI in E/M Leveling

    When leveling a GI office visit where the reason for the visit is to plan a screening colonoscopy with no presenting problems, what information are we allowed to use under the HPI section of an E/M Leveling sheet? My team lead and I are trying to determine if we can use "location" since we know...
  2. D

    Question HPI Copy and Paste

    I have a Hospitalist that copies the ER provider's HPI and pastes it into their note with "Per ER MD:" as the title. Is this allowed? My gut tells me no, but I have searched all over to find a guideline that specifically states that the provider must document in their own words, but have been...
  3. W

    E/M Coding ...

    Evening, Just want to double check with everyone to make sure I'm handling the following coding correctly. For this example I would code as a 99202, guidelines 1995. But with the oral decadron given and a prescription would this change to a level 3? CC: Ear pain for 3 days 27 year old male...
  4. W

    E/M Coding .

    Good Evening, Need anyone's insight regarding presenting problems. There was insight that I had received stating that a presenting problem that is less than 72 hours with a prescription being prescribed would be a 99203 instead of a 99202. Is this true? The following example I usually would...
  5. W

    E/M Leveling Question 3

    Prescriptions Good Evening, For Motrin, Tylenol etc...anything above 200mg needs to be prescribed?
  6. W

    E/M Leveling New patient

    Drug Prescription Evening, Motrin, Tylenol etc... when the mg is above 200 this would be a prescription?
  7. W

    E/M Question

    Drug Review Good Evening, What is the best icd 10 code for drug review? So far the best code I tried was Z69.89 but I received a msg stating cannot be billed as primary so trying to find the next best code to use for the encounter as primary. Thank you
  8. J

    INPATIENT --- Over My Head

    Hello! My name is Jordan and I am recently employed in a Colorectal Surgeon practice that also houses a GI doctor for IBD and they all do Inpatient rounds as well as procedures and surgeries. This office has lacked a coder, biller, A/R person for at least a year and is in just a mess. I have a...
  9. baroquecoder

    Medical Necessity beyond purview.

    I am being told that validating E/M's to some extent is beyond my purview. Specifically medical necessity. I am being told that it is beyond my scope to recognize/question/or validate E/Ms with regard to their medical necessity. I am being told that we are to 'assume' that if the MD states in...
  10. S

    ADD/ADHD Consults

    I had a meeting with my providers and a question came up about when they have add/adhd evaluations. They wanted to know if they are allowed to charge a 99213 even though they did not exam the patient. I told them let me get some advice and I will let you know. I thought about it last night and I...
  11. A

    Do you see a comprehensive exam here?

    Do you count 8 organ systems for a comprehensive exam? Patient is in a coma. VITAL SIGNS: BP 100/60, HR 90, Intubated on vent, sedated. Weight 171 kg. HEENT- face is cushingoid CHEST: bilateral rhonchi ABD: soft EXT: legs show edema NEURO: corneal and gag reflex absent. No movement or...
  12. A

    Does referring to a specialist or a "Consult" counts for "additional work up" ?

    Does referring to a specialist or a "Consult" counts for "additional work up" ? Does referring to a specialist or a "Consult" counts for "additional work up" when leveling e/m visits? and also what are some examples of "drug therapy requiring intensive monitoring from physician in the "risk"...