1. L

    Wiki Breastfeeding consult during Postpartum

    If a mother has a visit for breastfeeding consultation/instruction during her 6-8 week postpartum period, can you bill an E/M for the visit or is the visit considered part of the postpartum period?
  2. L

    Wiki Billing CPT 69209 - Ear Lavage

    So excited to see this new code added. Can anyone clarify if this code can still be used in conjunction with an E/M service as long as additional diagnosis' were covered to associate with the E/M?
  3. M

    Wiki Observation versus ER vist and in or outpatient E/M

    We are a private practice specializing in Orthopedic Surgery, with on call duties at the local hospitals. Recently we hired a new coder, who believes our physicians should be using the observation codes when called into ER or when the patient has been admitted by Hospital Medical Services. We...
  4. 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 . . . ?
  5. J

    Wiki Multi-Specialty E/M Coder Wanted (Remote 1099 Position) - Aviacode is looking for Mul

    Aviacode is looking for Multi-Specialty E/M coders (remote 1099 position). See the job description and how to apply here: https://goo.gl/Jb6tiS
  6. O

    Wiki 36589 without guidewire

    I have a surgeon who removed a dialysis catheter by simply removing cuff and pulling out the line (that is the documentation). Put pressure on for 10 min and bandaged. Coder assigned 36589 which I think is incorrect. I hesitate to reduce with /52. My initial instinct is to use an E/M code...
  7. M

    Wiki FP performing Consults?

    I have been stirring about this and I just cannot think of any examples where a Family practice doc would be billing a consult? I have a doc (who always has to "beat the system" in some way, shape or form) who all of the sudden wants to bill consults. I would think he would be the one sending...
  8. G

    Wiki Experienced CPC- Nashville, TN Looking for Coding or Office MGMT Positon

    I have tons of experience I have been certified w/ AAPC since 1999, I have over 16 years of billing, collections, insurance and coding experience! I have about 5 years of prior supervisory experience. I am with my current employer for 5 years now and have decided to look for a new position. I...
  9. N

    Wiki I&D w/ E/M?

    So I have a provider who performed a full E/M on a lesion, concluded it was an abscess and performed an I&D and gave an antibiotic perscription. My question is would this be an E/M-25 w/ 10060 OR because the E/M was directed towards the abscess would this just be a 10060? Its the wording...
  10. N

    Wiki I&d w/ e/m?

    So I have a provider who performed a full E/M on a lesion, concluded it was an abscess and performed an I&D and gave an antibiotic perscription. My question is would this be an E/M-25 w/ 10060 OR because the E/M was directed towards the abscess would this just be a 10060? Its the wording...
  11. S

    Wiki E/M MDM Table 1: Self limiting/minor vs. New Problem

    I have been an auditor for several yrs and have never considered a self limiting or minor problem as a New Problem on the Med Dec Making Table of Risk (Table 1) # of Dx or Management Options. In my opinion and due to the fact that there is a separate box for self limiting (1 pt), it would need...
  12. S

    Wiki Physical vs New PT visit

    My husband went to the Dr. and I have questions regarding the coding because I am so close to this I wanted the opinion of others before I question the office. Pt called up and requested physical examination due to being new in the area and needed to establish a PCP. Pt received bloodwork and...
  13. L

    Wiki High level E/M?

    Established patient with four problems - all of them follow-ups. Progress notes a short assesment of each one, and a treatment plan. One is a toe nail Bx, one gets an injection, the other two are treated topically. Doc says that because there are so many, he should get a 99215. I've got no...
  14. C

    Wiki Emergency Medicine

    am wanting to do a Emergency Dept webinar, I was considering two: E/M Coding for the Emergency Dept and Emergency Medicine- How to Accurately Code They seem very similar in what they teach you. and both are rated highly.( I wish AAPC let people actually review a webinar, to let others know...
  15. C

    Wiki PSYCH E/M Coder-Auditor in SALEM OREGON

    RMC is an Oregon-based coding review and coding support services company, founded to assist healthcare facilities in obtaining correct reimbursement and minimizing lost revenue through complete and accurate coding, documentation improvement, and education. RMC has been providing comprehensive...
  16. N

    Wiki HELP! E/M confusion (99214)

    The majority of the patients we code are established patients. I was taught always to use the MDM in the EM selection. However this has brought on somewhat of a confusion. In all documentation I've researched, I've found the same thing... it only takes one element of risk to qualify for that...
  17. L

    Wiki 2 out of 3 in E/M

    I have a provider who documents only two of the three key components for extablished patients, because only two of the three are required to assign the E/M. The result is no CC (just follow-up), HPI, ROS or PFSH. Is this code-able at all? Thanks, Lin CPC
  18. C

    Wiki Billing E/M Visit and Xray

    I need some help with documentation of some coding guidelines. I work for an orthopedic surgery practice and we are currently setting up our EMR to document E/M visits and have hit some road blocks. I have heard several different places that if you are billing for both the technical and...
  19. C

    Wiki Over/under coding Distribution

    Does anyone know if there is data showing an average, expected, "normal" percentage of over-coding or under-coding found in a physician practice? I have found a few articles where fairly widespread studies were conducted (e.g. 5 progress notes sent to providers to code, results compared to...
  20. L

    Wiki E/M "NEW problem" on auditing forms

    I'm pretty sure that this question has been asked and answered before, but I couldn't find it. If a consulting provider sees a patient with a problem that he/she has not seen before, but that problem is not new to the primary care provider (hence the request for a consult), is that considered a...
  21. D

    Wiki Inpatient vs Outpatient e/m code in a Radiation Oncology Center

    I work for a large corporation in the Northwest. We have a Radiation Oncology Center which is a 'stand alone' facility. We have patients who are admitted to the hospital and while in the hospital are referred to the Radiation Oncology Center to discuss treatment options. They do NOT discharge...
  22. L

    Wiki Modifier usage for National Exam

    I'm confused. I'm taking the National Exam in a month, and I am taking an on-line course in preparation. AAPC has provided the instructor with all the answers for the Step-by-Step text book. The instructor keeps crossing out things and writing in her own. The latest one: Well baby check-up...
  23. B

    Wiki Bronchoscopy and Subsequent Hospital Visit

    I have found the following scenario when auditing for our pulmonologists: patient admitted to hospital, pulmonary consult is requested and done. The consult report states patient will need a bronch. Q 1. Does there need to be a request in the medical record from the attending...
  24. K

    Wiki Shared Medical Record

    Hello - I am in need of some expert help. I need to clarify the meaning of "shared medical record". Here is a scenario: A group of several entities/facilities enter data to the same electronic record system. All entities involved have access to the whole system. Would this be considered a shared...
  25. R

    Wiki OBGYN Observation Coding

    Our facility participates on a Residency Program which provides OBGYN teaching. Should an E/M observation code (99217-99220) be billed or E/M outpatient code (99201-99215) when the patient is on Labor and Delivery for 24 hours or less? Thanks.
  26. S

    Wiki Break by specialty?

    I wonder if it wouldn't be easier if this thread was broken down even further by specialty or even subject. For example Family Practice, Pediatrics, Surgery, Radiology, etc.... OR E/M codes, ICD 9, CPT etc....Just a thought. So glad this Forum/Message Board is finally available. Michelle Z. CPC