note

  1. B

    Teaching physician documentation

    If a provider states that “patient seen and examined. Agree with above note”. Does this suffice for an attestation of a residents note?
  2. R

    Attendance at Delivery

    If a resident is billing an attendance at delivery and the attending doctor is in the hospital, do we need the attestation on the note as we would in all other situations? Thanks
  3. U

    Colonoscopy in outpatient setting

    Hello. Wanted to get some clarification. :) Colonoscopy- physician introduced scope through anus and advanced to the terminal ileum, with ID of the appendiceal orifice and IC Valve. The colonoscopy was performed without difficulty. The quality of the bowel preparation was fair to poor. He did...
  4. B

    Documentation Requirements

    A patient comes in today for an office visit. At todays office visit the dr order the patient to return at their convenience for fasting labs work. Patient returns 2 weeks later for fasting lab work. What are the documentation requirements for the day that the patient comes back fasting and...
  5. L

    Critical care

    How much critical care time would you bill in this situation. Provider initiates care 02:30 he signs his note at 03:43. Never says critical care time spent anywhere in his note. Patient was seen in the PICU - which I know doesn't necessarily mean critical care. He does an addendum starting @...
  6. B

    Coding an Op note

    What can I use to code an operative note for professional side? Can I use the encounter note with the decision to go to surgery along with the op note? Or do I only code from the op note? Do you have anything in writing on this? Thank you for your help in this matter BobbieJo
  7. E

    Split/Shared IP/OP Hospital Consults

    When a PA Hospitalist performs a IP/OP consult in the hospital without the MD present. Does the MD Hospitalist have to have a face-to -face visit with the patient and also document elements of the visit in addendum to the PA's consult note that they performed personally? -or- Can the MD just...
  8. A

    Questions on AWV documentation

    Our practice is new to doing AWVs and I want to make sure we are documenting all the requirements appropriately. I've been reviewing the CMS document for AWVs: https://www.cms.gov/Outreach-and-Edu..._ICN905706.pdf, and I have a couple of questions. The required elements list ADLs and IADLs...
  9. A

    AWV Element Questions... need help please.

    Our practice is new to doing AWVs and I want to make sure we are documenting all the requirements appropriately. I've been reviewing the CMS document for AWVs: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf, and I have a...
  10. M

    modifier 24 - I have a biller

    I have a biller who says a 24 modifier is appropriate on a claim and I question the validity. Looking for validation for the following scenario: Patient had several procedures in June 2015, only 1 of which has a 90 day global, CPT 46930 Destruction internal hemorrhoid. In early Sept 2015, still...
  11. C

    Shared Visit?

    A CAH has one group covering both the ER and hospitalist services - internal med providers. Providers assigned to ER (usually a PA or NP) document their note, then provider assigned to hospitalist (MD/DO) does the admission (to Obs or Inpatient). Since they're one group, one specialty, both...
  12. M

    Coding/Billing for Diagnoses

    My provider wants us to use co-morbid conditions when proving medical necessity for urine drug testing (we work in Pain Management). However, these co-morbid conditions are not always noted on the note for that visit. I am hesitant to use codes that the doctor hasn't documented in the note...
  13. M

    Wiki Coding for sore throat/pharyngitis

    When a provider orders a strep test and reports dx code R07.0 (pain in throat) and then the strep test comes back positive so the provider also assigns J31.2 (chronic pharyngitis) should the diagnosis R07.0 be removed from the visit note? I know these 2 codes cannot be billed together, however...
  14. M

    Procedure Titles

    When a procedure is being done in the office does the procedure note need a title? Example: Nasal Endoscopy. We are having conflicting issues with this, stating the procedure note done does not need a title for a procedure. I believe if you do a procedure you should have some kind of title...
  15. S

    Wart removal by cryotherapy

    New to dermatology... Would you use 11200 or 17000 for wart removal? Note states: liquid N2 applied to wart on finger.
  16. M

    Code First note

    Hello, If a dx has a code first note but none of the code first dx's listed apply to the pt can this dx still be used? ex: sepsis A41 other sepsis states code first postprocedural streptococcal sepsis streptococcal sepsis during labor streptococcal sepsis following abortion etc, etc. none of...
  17. K

    xrays

    Due to the 2016 CPT changes will x-rays still be allowed to be dictated in the body of the followup/progress note to be charged for or do they have to be a separate report?
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