history

  1. V

    Question Pain scale

    Established pt coming with worsening knee pain, severity 3/10. In this case in MDM part for num# of diagnosis table A, how many points will we consider for this problem?
  2. G

    Pulling from HPI

    Can someone give me an idea of number of elements that can be pulled form this HPI. New patient Provider wants level 4 (99204) Provider states 4. Also, I have a coworker who states we can use Indication: colon cancer screening as a Location, Does anyone know if this is correct? Chief...
  3. M

    Code for levated BP no longer present.

    Code for elevated BP no longer present. Our provider saw a patient with elevated blood pressure without diagnosis of hypertension. At the follow-up visit the patient's BP was back to normal. What diagnosis code is used for the follow-up? I can't find any personal history codes related to...
  4. Rebecca Pate

    Help with HPI points for new patient

    I need some help with this one. "25 year old patient presents for initial visit. Husband is in the military and was transferred here 5/2017. She is here to establish care. She saw her GYN 2/2017 and IUD was still in place." This is all there is in the HPI. Everything else is fine, but I...
  5. D

    Consult/Hospital Visit/Subsequent ???

    For inpatient neurology consult coding. HPI ROS PFMSH EXM MDM My question is that there is also a Neuro Exam which consist of Gen app-(1), Vitals 3 vitals (1), Fundus (optic disc exam (1), CV (pulses, bruits, or auscultation of heart (one point Maximum), Mental status (5), CN (8), Tone...
  6. P

    DVT vs History of DVT/Pulmonary Embolism

    I am a HCC coder and we are having a debate in my office about coding DVTs and pulmonary embolisms. Most of the physician notes we review just say something like "DVT - on Coumadin" I have been told not to code a DVT or Pulmonary Embolism unless the patient is presenting to the hospital or...
  7. M

    ROS acceptable or not----Adivce please

    Hi, Is this acceptable or not? Provider uses a form for the Review of systems that patient fills out. There is only 8 systems listed with the associated symptoms listed with it. The patient is suppose to circle all that applies or has experienced recently; which in this case nothing is...
  8. W

    Icd 10 for 2 vessel cord ultrasound & maternal history codes

    Hello, I am new to OB coding and really could use some input. We have several patients receiving serial ultrasounds and BPPs recommended by Maternal-Fetal Medicine due to dx of 2vessel cord. Of course there is no exact ICD10 code for this condition for maternal care. I've looked at 2...
  9. T

    E & M coding help please

    Please help with correct E&M code new patient office visit an expanded problem focused history, comprehensive exam MDM of high complexity what will the E & M code become
  10. L

    Does this qualify for the family/social/past medical history??

    Our doctor want's to charge a 99214 for this visit. I'm curious if you can use the family history, social history, and personal history when it says just 'no changes' as he did below. Does that qualify or does he have to reference the date of the last time it didn't change. For example if it...
  11. S

    Wiki History of Vitamin D Deficiency

    Can anyone give some feedback on what code to use for a history of Vitamin D Deficiency? We have had a lot of discussions regarding this, and the best code we can come up with is Z86.39.
  12. N

    ? abuse , use , remission

    so if a patient has doc. IVDA positive heroin and the provider states in rehab would this be coded f1120? I could not find any history if IVDA. I might be wrong but I thought icd 9 had history
  13. T

    injection only to be billed out?

    I don't see anything coming out to be able to bill the E/M with the injection. any thoughts?? I am still trying to understand and learn the E/M. its fairly new to me. 1. Right knee pain. HPI: Appointment type: Established patient - Established problem Patient returns for his right...
  14. A

    ICD-10 Inpatient facility R/O and H/x

    I work for residential behavioral health facility that serves children and adolescents. I am not sure how to code "rule out" and "history off". For example I have on my summary report history of ADHD or R/O ADHD. Is the F90.9 correct code for both scenarios ? Please help me :)
  15. J

    History of Acute Chest Syndrome in Sickle Cell Patients

    How do I code a history of Acute Chest Syndrome (not a current dx) for Sickle Cell Patients?
  16. T

    can we bill an office visit with the injection??

    Chief Complaints: 1. Bilateral hip. HPI: Appointment type: Established patient - Established problem Patient returns for the MRI results of both hips. She denies any other complaints . ROS: Unchanged from 12/16/2015. Medical History: Infection, headaches...
  17. T

    can we charge office visit with the injection???

    can we charge the office visit with the injection?? please any help appreciated. Chief Complaints: 1. Bilateral hip. HPI: Appointment type: Established patient - Established problem Patient returns for the MRI results of both hips. She denies any other complaints ...
  18. H

    History of Anatomical codes, why is hand modifier -FA for thumb rather then a number

    I am try to figure out the history behind why with both hand and foot anatomical hand modifiers that the left thumb is -FA rather then a -F(number) like the rest of the fingers. And same with the toes.
  19. C

    Billing an annaul & E/M at the same time.

    It is my understanding that the annual exam needs a complete past, family & social history. pt. also has a level 4 (99214) illness, how do you separate the history for the annual and the E/M code?
  20. G

    Code symptom or history code first?

    Just curious. Does it matter if we code the history code or the symptom code first. No other diagnosis code is use. Thanks.
  21. E

    History of Polyps - Need some input please

    Need some input please; If a patient comes in for a colonoscopy, non-Medicare, with a history of polyps (tubular adenomas)last colonoscopy over 10 years ago, is this an average risk colon screening or a surveillance colon? Is there any where that states if a patient has not had a colon in over x...
  22. T

    Family History - they can't document

    My provider keeps documenting non-contributory under family history, so does anyone have any reference material that clearly explains how they can't document this way? I can't seem to find anything, so any help would be greatly appreciated!
  23. bproosow

    Active or History? Follow-up oncology visit with no further treatment

    We are having a heated debate here on this subject. Here is the scenario: Patient has cancer, let's just say colon cancer. Goes in for hemicolectomy. Surgery goes well, margins are clear, NED. Up to this point we are coding for the colon cancer. Patient goes for his first follow-up visit with...
  24. bproosow

    Coding for post-op oncology visit with no further treatment

    We are having a heated debate here on this subject. Here is the scenario: Patient has cancer, let's just say colon cancer. Goes in for hemicolectomy. Surgery goes well, margins are clear, NED. Up to this point we are coding for the colon cancer. Patient goes for his first follow-up visit...
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