1. KStaten

    Wiki What Designates an "Active Involvement" in Plan of Care?

    Hello Everyone! 🙂 According to what I have read (in regards to incident-to billing), in order for a patient to be seen by the PA and still be billed under the doctor, the doctor must do the following: 1) Initiate the treatment 2) Continue to be "actively involved" in the patient's case/ plan...
  2. K

    Wiki Physician and Coders

    Our practice currently has 4 Physicians, 2 Nurse Practioners, 1 Physician Assistant, and 2 more surgeons have joined our practice with one starting in August and the other starting in October. Our totals will then be 6 surgeons, 2 NP, and 1 PA. I have 1 certified coder who does all of our...
  3. M

    Wiki Signature for Progress Notes

    I'm pretty sure i Know the answer to this but I want to see what everyone else thinks. If you have a group practice and the Physician is out on vacation so a nurse practitioner sees the patient and signs the chart i know this is "incident to." The ordering physician comes back from vacation 2...
  4. M

    Wiki Physician Review Conference

    When a physician is doing a review conference; meaning they are telling the patient the results of their skin test or any other test they may have done, what information needs to be included on the encounter in order for it to qualify for an E/M service code?
  5. M

    Wiki Ordering Physician

    I saw that this has been asked a few times, but no answers. When sending out a claim for diagnostic services such as a CT is it ok to add the ordering physician that may not be in office but at another one of our satellite facilities? The doctor is on the schedule just not at the location that...
  6. 2

    Wiki Certified Physican Surgery coder with 9 years experience looking for contract work

    CPC certified with 9 years experience in multispecialty physician coding surgeries, E/Ms, and denials including pain management, cardiac, cardiothoracic, neurology, ortho, OB/GYN, gastro, urology, podiatry, dermatology, anesthesia, family practice, peds, ENT. Surgery coding is my passion...
  7. K

    Wiki Nephrology - coding inpatient

    I am new to coding inpatient hemodialysis for physicians and I have a question about documentation. When the doctor sees the patient while on dialysis, do they have to actually document, "patient seen on dialysis"? Also if they are on CRRT, is it assumed that they were seen while on dialysis...
  8. K

    Wiki Nephrology

    I have a question about coding rounding for a Nephrology physician. He sees the patient on dialysis, which he documents, does he have to write the diagnosis on each progress note? Or can you go back and use the dx from the initial visit? This is for the physician fees. Thank you for any...
  9. M

    Wiki Chemotherapy Physician Charge Clarification

    Hello All. I was hoping someone could help clarify a scenario at my job. I work for an outpatient Cancer Center that is part of a hospital. One of the physician's questioned how the company that handles his professional billing can successfully bill and be reimbursed for observation of the...
  10. M

    Wiki physician assistant as referring or use her supervising physician for audiology

    Requesting some help on physician assistant billing and compliance. The physician assistant is filing under her own information for a evaluation and management visit because her supervising physician is out of the office. She sees a new patient and determines they need audiological testing. The...
  11. M

    Wiki ACR website physician fee schedule versus CMS physican fee schedule search

    I printed off physician fee schedule off of ACR website. It is a bit different than physician fee schedule search via CMS. Which one would you use? Doesn't seem to be but a couple of cents off.
  12. S

    Wiki Burn care

    If Patient came with second degree or third degree, But physician provides the treatment of first degree, can we capture 16000.
  13. B

    Wiki 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...
  14. L

    Wiki Two practitioners, one visit

    A patient came in with shoulder pain to see our NP, who did all of the charting for the E&M(99213), then Our physician came in and gave her a trigger point injection(20610) of Kenalog(J3301) How is this coded?
  15. K

    Wiki Level 5 E&M with Oral Challenge

    Good Afternoon, I am looking for confirmation of my assumption regarding this scenario more than I am an answer to the question. Is it appropriate to bill a level 5 E&M in addition to the code for an Oral Challenge if the patient does not require physician intervention for anaphylaxis or...
  16. D

    Wiki Documentation - like an addendum

    Can we tell the physician what is missing in their HPI? Like if they are not meeting all the criteria can we tell them what is missing so they can meet it? If so, how do we know that the physician performed/gathered all the information? can they add it after the fact like an addendum?
  17. S

    Wiki 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...
  18. D

    Wiki hospital billing 99283

    I have a question, if the doctor seen the patient in the hospital and they bring all the papers back and there is no referring or attending physician can this be billed without will this get denied?
  19. U

    Wiki Dexa Scan

    Hi everyone! I was reading over some of the old threads regarding the dexa scan, 77080 and I had a question. The physician order states "Dexa Hip & Spine" with 256.39 (this DOS is prior to ICD-10), estrogen deficiency. This is exactly how the coder coded it. I am working the denial from the...
  20. D

    Wiki E/m auditing

    When an established patient comes in does the physician have to update their exam or can they just carry it forward from a previous visit? If they change/add one thing to the exam (one section not the whole exam) does this allow them to use the complete exam from the previous visit? On the...
  21. M

    Wiki 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...
  22. J

    Wiki 2016 Physician Fee schedule

    I deal with IP but I am trying to help a friend who is a new coder, the medical practice has a new owner/manager in the process of changing EHR. Is there an easy place to find the 2016 Physician Fee Schedule; the CMS website is making me dizzy. Thanks JC
  23. C

    Wiki Help!!

    Does anyone know if the overseeing physician has to be credentialed in the specialty of the nurse practitioner who will be seeing the patient? and if the overseeing physician can review charts digitally? And will telemedicine be acceptable for incident to billing???? If anyone can help answer...
  24. N

    Wiki ER vs Inpatient E&M code

    Hi everyone! Any help would be appreciated!!! Neurosurgeon is on call. He sees the patient in the ER, but, the patient is admitted the same day. Do I code as an inpatient or do I code the ER consult? I was told that only the ER physician can code ER consults. And, per Medicare of VA, you can no...
  25. D

    Wiki Ent and audiology and medical decision making

    I have a physician who sees a patient, sends them to the onsite audiologist and then the patient comes back to see the physician again (all on the same visit, has never left the office). The physician reads the printed audiology report from the machine showing hearing levels,etc. (not the...
  26. A

    Wiki When should i be using modifier AI for hospital based coding?

    From my understanding you append a Modifier AI if the physician billing for the charges is the same physician that admitted the patient. Can someone please elaborate on this for me. and provide examples if possible. That would really help me put it into perspective.
  27. L

    Wiki Physician coder needed for onsite full time position Ruston,LA

    Currently looking for a full time coder for a multi specialty physician practice in Ruston, Louisiana. Job is an onsite position. M-F / 8-5. Please send resumes to or fax to 318-251-6116 attn: LKnight
  28. K

    Wiki Advance Care Planning 99497-99498

    Description for these code state when performed "by physician or other qualified healthcare professional." In our situation, physician talks to patient for about 5 minutes and then sends the patient to the social worker who spends another 45 minutes with them filling out forms. Would this be...
  29. L

    Wiki ABThera closure of abdomen

    Please help! The physician placed an ABThera vac after a small bowel resection on a patient with an ischemic bowel. As per the physician the ABThera closure is not a normal vac it goes inside the entire abdominal cavity and states it is similar to a "bogota bag" and is disposable. I have...
  30. R

    Wiki physician coding-down coding?

    Hi. the orthopedic physician excised a bone lesion of the tibia and closed it with an allograft-27638. per coding guidelines you can only code for the allograft as the excision is inclusive. He wants to code for an excision w/ a biopsy to get higher RVUs-27635 and 20245 instead. Is this...
  31. N

    Wiki Advanced Care Planning-The new ACP

    The new ACP that can be done w/AWV, states that there is a 30 minute code of 99497, and each additional 30 minutes is code 99498. What are the guidelines if the physician only spends 20 minutes doing the Advanced Care Planning. I can not find any information on if the physician spends less than...
  32. T

    Wiki Injections with no provider on site

    Hi there! Can an RN, LPN, CMA or RMA give an injection (Haldol, Abilify, Risperdal, Invega Sustenna) without a supervising physician on site at the time of the injection? If yes, please give me a resource that I can give to our clinical team that supports it. CPT states "Do not report 96372...
  33. J

    Wiki Physician Orders for Lab/Diagnostic Tests

    Billing for facility: Orders from physician are coming over without a dx or an acceptable 1st listed dx. Facility is providing these services and we cannot code them without clarification. Is it inappropriate or correct coding/billing standards to bill/accept orders for labs/diagnostic tests...
  34. C

    Wiki Physicians Not Specific Enough

    Hi Everyone, first time posting, so hopefully this is the proper thread! I work for a company that does billing, coding and collections for outpatient surgery centers (ASC). We are increasingly running into problems where our coding of operative reports does not match up with how the surgeon's...
  35. S

    Wiki Standing Orders

    I have a situation where a practice has nurses see patients under standing orders for immunizations, TB tests, and some labs. They want to bill these services under the chief of staff NPI number (due to the standing orders). The situation, I feel has gotten out of hand. Nurses may triage a...
  36. C

    Wiki Drain tube removal by another physician.

    How would I code for this when the patient did not want to drive 5 hours to the physician that performed the surgery and inserted the tube and, instead, decided to do it locally. What CPT should I use and ICD-10-Code? Please advice. Thanks in advance!
  37. C

    Wiki DL with Rigid Bronchoscopy

    Two questions: When a physician states pre/postoperative diagnosis of "Failure to extubate", all the literature I read states the physician should indicate the reason for the failure and that should be the diagnosis. What are your thoughts? I have a practice that completes DL and Rigid...
  38. A

    Wiki No exam done, can E&M be billed???

    If my physician is seeing an established patient and no physical exam is done, can I charge an E&M visit? I have read in a couple places that even though you only have to have 2 of the 3, if an exam is not done, it's not considered a visit. When patient's come back for MRI results, the physician...
  39. H

    Wiki Office surgery vs otpt surgery

    Can a physician schedule a surgery in the office (place of service code 11) and take the patient into the ambulatory surgical center (place of service code 24) and bill only the physician portion with place of service code 11? Example: A physician schedules a YAG in the office. Physician takes...
  40. M

    Wiki In Home Billing by a Physician

    I wanted to get information on In Home Billing by a physician. I have a physician that wants to partner with a hospice company and treat the patients that are unable to leave home. I want to confirm that for a Physician I would use codes 99341-99350. Also, I want to know if the physician...
  41. S

    Wiki Charge for paperwork

    A patient came in just to have paperwork filled out by the physician. Can we charge the patient for this? Thanks, Caroline
  42. T

    Wiki 52 vs. 53 modifier

    When a physician is unable to insert an IUD what modifier is used?
  43. R

    Wiki Need assistance on ER leveling.

    Case #1.. Patient came in with final DX of strain of muscle/fascia on lower back. Complete HPI, ROS and Exam. physician did x-ray and prescribed Norco q6 PRN. (not admitted) They recommend 99284 code , as I was thinking it was just 99282 or 99283? Case#2.. Final Dx: Contusion Left Hip...
  44. A

    Wiki E/M Leveling

    When coding for outpatient physician visits do i consider the diagnosis Z23-incounter for immunization as a diagnosis for the overall leveling of the e/m code??
  45. K

    Wiki L4 to Ilium instrumentation

    My physician only placed wires and screws from L4 to ilium. The instrumentation codes I normally use are "add on" codes. Can anyone tell me what I should use here?
  46. C

    Wiki FT onsite, coder needed

    Oklahoma City - Large multi-specialty physician group. E/M experience helpful. Please contact Terri @ 405-553-0852, for more information.
  47. E

    Wiki Urgent Care/Walk-In Clinic Incident-to Billing?

    Question: For a walk-in/urgent care clinic, the rendering provider is a PA and there is a physician on site that is the supervising physician. The claim is billed out under PA rendering and Doc supervising. The supervising doc does electronically sign the note, but the supervising doc is not...
  48. A

    Wiki Radiology Professional Charges

    I am getting conflicting information so if someone can answer my question and tell me where to find the rule I would really appreciate it. I code Radiology and Interventional Radiology and with the new ICD-10 some are saying that my coding should only be off of the patients s-ray report or order...
  49. Jennifer CPC

    Wiki 99485 & 99486

    HELP...I have contacted the AAPC and the AMA regarding this and I still can't get an answer. In the 2016 CPT Professional Edition by the AMA on page 43 left column about half way down it states "Code 99485 is used to report the first 16-45 minutes of direction on a given date and should only be...
  50. A

    Wiki Physician billing for test ordering

    Can a physician bill for ordering certain tests? For example breast cancer screening, colon cancer screening. The tests will not be done in the office but can we still bill for the actual ordering of these tests? If so, what CPT codes should be used?