1. T

    Patient Apps

    Hello, We are a small allergy, asthma, and immunology clinic. We are looking for an all-encompassing HIPAA secure app that allows patients to communicate with us, schedule their own appointments, see their balance and pay bills, complete intake forms, etc. Any recommendations?
  2. G

    Patient Calls with insurance info after filing limit.

    If a patient was seen and did not present insurance and was billed for the visit, decides to call with insurance info well after the filing limit for their insurance, are they responsible to pay or do we have to write it off?
  3. L

    E/M vs Preventive Visit

    Patient states was only see for annual physical exam provider billed e/m with diagnosis. The CC & HPI both indicate patient was being seen for annual routine exam and the ROS and Exam portion also support this. Is it reasonable to code a routine physical Z00.00 even though the providers...
  4. T

    Fracture care - ATV accident

    Hi there! I have a billing question.. Patient came into our office after a ATV accident. He did not go the ER or anywhere else. The Patient Hurt is left arm Dr noted a Distal radial fracture nondisplaced. He did put a Don joy cast on his wrist but the Patient had to be sent out for Xrays since...
  5. C

    Preventive physical exams, Medicare patient

    Hi everyone! Before I continue I want to clarify that this has absolutely nothing to do with the Medicare AWV. This is a hands on, head to toe, physical exam. A patient comes in every year and has the same thing, clearly documented, coded 99396 through age 64. Now this patient is on Medicare...
  6. U


    We have a patient who cannot tolerate the full dosage of bcg. If we give him only 1/3 of the dose can we bill for the waste? He is a medicare patient. Thank you
  7. C

    PIP fracture Dislocation Surgery report help

    Please help advise me on this procedure. My physician likes to review his surgery coding before they get submitted to insurance and approved the codes billed out. He does this procedrue quite frequently and we always use 26535, Same diagnosis, same procedure. He is now wanting me to use 26746...
  8. O

    Bone Density study with Office visit

    Our physician wants to bill office same day as bone density study, is this ok to do? Here is his note. Patient is here for osteoporosis consultation for bone density done on ????. The report is in the chart, see report for full details. The study was consistent with osteoporosis. The...
  9. W

    Psychological Testing

    My Doctor just met the patient 90791, Can I also use 90785 as the visit was 1 1/2 hours. During this time she also did testing and some interpretation. She met with the patient again for another hour and also wrote an evaluation(4 hours) for his court appearance. I am so confused on how to code...
  10. J

    New Patient visit with no Dx?

    I have run in to an issue where one of my providers has a new patient appointment where all the patient wants to do is establish a relationship with the provider. This patient has nothing medical wrong with them (not on any Rx nor has any chronic issue and not currently sick). What dx code would...
  11. C

    Open Billing Specialist Position - UTSW

    Hello- Please go to the UTSW Careers Website to apply. Here are the details: Billing Specialist I - Obstetrics & Gynecology -Women's Center Job Number: 520271 Categories: Insurance / Billing Location: Dallas, TX Department: OB Gyn Women's Center Full/Part Time/PRN: Full-Time...
  12. S


    How many months back can I bill for 30 minutes of CPO for a patient? Or does it only have to be the current months to months?
  13. S

    Initial or subsequent MI?

    Hi, I would like to ask for your input regarding coding initial or subsequent MI. I have a patient who was admitted due to SOB. Patient had an NSTEMI 2 weeks ago. Later during the admission, patient became bradycardic and reported chest tightness. A code was called . Monitor showed...
  14. A

    Trigger Point at Bedside

    Patient was supposed to go to surgery for a lipoma removal and a shoulder trigger point injection. The patient never made it to surgery and while in holding they did the trigger point injection. I know we cannot charge OR charges but can we still charge for the injection?
  15. M

    Billing for microscopic examination of hair

    Is anyone aware of a code for the microscopic examination of hair collected by the patient and sent in to the clinic?
  16. M


    Can someone let me know if a LPN can plant the PPD for a patient? I know a RN can but not sure of the LPN. Also, the company I work for is now accepting CIGNA health plans and want to pilot PPD since its a required test needed for employees. Can a patient just get a PPD without an OV? Thank you!
  17. M

    Microscopic hair examination

    Is there a code to bill for microscopic hair examination when the hair is collected by the patient and brought in to the clinic?
  18. K

    99204 and 95970?

    If a Provider does a new patient visit and documents the following under NEUROLOGICAL PHYSICAL EXAMINATION: Integumentary: His incision is well healed without edema, erythema or tenderness. His vagal nerve stimulator was interrogated and did not indicate a low battery Is that sufficient...
  19. J

    OB pt w/ elevated BP

    how do you code a patient how came in with elevated BP but the doctor is not calling it gestational hypertension yet. she sent the patient home to do a 24 hour urine test. should I just append the R03.0 elevated BP?
  20. E

    Cystoscopy, R stent insertion, bladder stone extraction

    Pre-operative Diagnosis: Obstructing R stone Post-operative Diagnosis: Obstructing R stone Procedure: Cystoscopy, R stent insertion, bladder stone extraction Operative Indications: 61 y.o. male with an obstructing R-sided stone with concern for sepsis. The risks of the procedure...
  21. T

    Pre-Op Visit for Screening Colonoscopy

    My director wants to bill for preop visit for patients who are coming in for screening colonoscopies. Instead of the nurse doing the H&P over the phone, the patient would come in and see the nurse practitioner. Could we bill a low level E&M code for this?
  22. N

    Application of casts and strapping

    We have a situation that has created quite a debate in our office that we could use some advice on. Here's the scenario: a patient presents to the clinic with a fracture. The physician evaluates the patient and stabilizes the fracture with casting or splinting prior to surgery at a local...
  23. C

    observation codes for cardiologists

    We are a cardiology practice that is called for services provided in the hospital. I am having quite the issue understanding exactly how to bill observation codes. When our group is consulted to see the patient what code should we be billing if the patient is already admitted to observation...
  24. M

    99144 Conscious Sedation in Pain Management Office

    Hello, I was wondering if someone can assist me in how to document for Conscious Sedation in an office setting for Pain Management. We currently just use something like "Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse." I am received denials...
  25. B

    bundled or billable

    Hi I hope all are doing well... Please share your suggestion on this. As per documentation, patient got admitted in ED with the complaining of abdominal pain then patient found to have gallstones by ED physician (99284). Finally patient got discharged and admitted as inpatient care settings on...
  26. G

    INPT/OPT admision and discharge same day

    Patient was admitted to the Observation on 1/31/2016. The admitting physician gave the orders over the phone on that day at 5:50pm. He saw the patient the next morning (2/1/2016) and did the H&P. Then, patient was discharged from the Observation on the same day at 4:10pm. How should it be...
  27. D

    Coding for Hospice patient when provider is not the Hospice provider

    We had a patient come in to our office that is a Hospice patient in another location. He was seen for several problems unrelated to his hospice diagnosis. The provider also mentioned his terminal diagnosis in the progress note. Can I bill this with a condition code 07? For treatment of...
  28. 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...
  29. 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...
  30. J

    OB visits for medicaid patients

    what do you bill for a OB visit for a patient with no complications. do you use the ACOG prenatal flowsheet? Currently we bill a 99213 but I am questioning the MDM if the patient is having no complications?
  31. C

    Out patient visit vs observation

    I have a coder who is billing out patient e/m visits for patients who come in as ob triage / and h *& p is completed on patient. Is this the correct way for coding out patient/ in bed ob traige visits?
  32. K

    Emergency room visits using t sheet

    When a patient is evaluated in the ER and a T sheet is filled out by a ER nurse and she documents Right Ear Pain. The physician then comes in and evaluates the patient and diagnosis Acute Ear Pain, but does not use laterality ie Right or Left. Can the coding be done as Right ear pain...
  33. R

    colectomy without colostomy or anastamosis

    I have surgeon who did an open procedure on a patient who had two perforations in the colon, one in the descending and the other in the simoid. Surgeon divided the colon just distal to the sigmoid and proximal to the descending but left the patient open with a ABThera wound vac. No Anastamosis...
  34. S

    new patient vs. established patient visits after a pratice buy out

    We have a group practice (group A), pain management specialty, wanting to buy out a single Dr practice (practice B), also pain management specialty. The group practice (A) wants to know if they will be able to charge new patient visits on the single Dr practice's (B) established patients after...
  35. J

    Two consults for the same NPI, admission to the hopsital and transfer to rehab

    Can someone clarify this for me: The patient is admitted to the hospital and we bill for the cardiology consult. Five days later the patient is transferred to the rehab floor in the same hospital and we see the patient again there due to a hematoma and he is on Coumadin. Do we bill both...
  36. K

    Combining Time in a split/shared visit

    Are you able to combine face-to-face time between the patient and the NP and the patient and the Attending in a split/shared visit to determine one time based code? Example: Patient comes in to discuss treatment options for urinary incontinence. The Provider has a face-to-face discussion for 15...
  37. C

    Incomplete stress test

    A patient came into cardiology as an OP for a stress test. Patient was only able to walk on treadmill for two minutes. EKG tracings and pulse oximetry , blood pressures where being monitored. Patient stated just cannot walk anymore "I am out of gas". Patient never achieved qualifying Heart...
  38. C

    HPV Vaccine given to patient over 26

    Hello, One of our providers gave an HPV vaccine to a patient over the age of 26. Obviously Medicaid denied the 90649 code due to patient age. In cases like this, do I just go back and tell the provider we cannot bill the HPV vaccine because of the age? Does the provider need to add an append...
  39. C

    Screening Colonoscopy and Anestheisia

    Screening Colonoscopy and Anesthesia If a patient is having a screening colonoscopy G0121, G0105, or 45378-33. Lets say a non-medicare patient was coded with a G0121 and DX Z12.11. G0121 is accepted by most commercial insurance companies so this should be fine. When its time to bill...
  40. S

    ER Consult Coding Clarification

    Hello Everyone! I hoping I can find some help in a situation that has come up with correct coding. So the scenario is as follows: ER doctor (Dr. A) calls in my physician (Dr. B) for a consult. Dr. B sees the patient in the ER and after this consult Dr. A decides to admit the patient. Dr. B...
  41. S

    Bill established then bill new patient code?

    Is there any documentation that addresses whether you can bill an established code prior to billing a new patient code? This seems counter intuitive however, we have a situation where we have an Immediate Care clinic that is modeled after an Urgent Care (without the Urgent Care designation.)...
  42. T

    Medicare Pt. Office Visit prior to colonoscopy

    I have a physician who saw a patient in clinic today prior to her being scheduled for a colonoscopy. Patient has a history of PE and is on anticoag therapy. He is doing a lovanox bridge with this patient, and took a great amount of time with her to explain all of this. Can he bill the office...
  43. C

    Vaginal delivery/ placenta/coding assistance

  44. T

    Low birth weight code being denied

    I have a patient that was born prematurely and was coming in for weight checks to monitor growth. The physician is still using the P07.10 code even though the patient is gaining weight because they are still below normal. The patient is now 3 months old and we are getting denied for...
  45. T

    Prp injection and ov

    I have a doctor who wants to charge an ov with a PRP injection. The PRP injection was cash pay. Can you still charge the ov with knowing the patient is coming in for the PRP???
  46. C

    Assistant coding out patient / hospital setting E/M code

    Sometimes the providers do the H&P on OB patients who are seen in the labor and delivery floor. However, it states patient are seen as out patient. Do you bill an out patient e/M code or do you bill observation codes? It doesn't mentioned patient is on observation status... I would like to say...
  47. V

    Is this Case Inpatient or Outpatient?

    A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. This is just an example of a case that doesn't mention that it is inpatient. This case...
  48. V

    Carcinoma of the Brain

    A 65-yr old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic...
  49. M


    Patient was seen in office 2/1 labs drawn office visit and injections billed, lab calls at end of day with critcal lab values and patient is called to told to present to ER for admission, patient waits until 2/2 and comes back to office and JUST picks up admission orders, physician does not see...
  50. M

    Physician coding

    2 questions: 1. Patient is seen in office and physician decides to admit to hospital, sends orders with patient, I am to bill and office visit and NOT an initial hosptal correct? 2. Same patient had an EGD on day 2 of hospital was kept for a few hours then discharged to home, can I bill a...