1. C

    Dg linking to plan

    Is it a requirement to have the plan show the direct link to the diagnosis code within the office note? Or is it acceptable to have a problem and diagnosis list separate from the plan documentation?
  2. T

    Occupational Therapy Plan of Care

    Is there a code that I can bill for an Occupational Therapy Plan of Care? I have researched and have not found one. thank you, Trish
  3. M

    Wiki Z79.4 Long Term Insulin Use

    Has the guidelines/description changed for Long Term Insulin Use from ICD-9 to ICD 10 to include use of long term DM medication as long term insulin use too? I have received information from several parties that CMS and plan are now including long term DM medication with the code of long term...
  4. A

    Low medical decision making

    one of our pa's consulted a patient in OBS...she did a complete hp, complete exam..but the plan is awaiting MRI results. Any suggestions on the medical decision making?
  5. J

    E & M documentation requirements

    I have a doctor that dictates his consults with a one line history of present illness and a very short plan and the P.A. does an extensive consult. Does the doctor need to dictate more extensive or can we base our code on the P.A. and the little the doctor dictated? The plan indicates a heart...
  6. M

    Cataract surgery

    What code should i bill. My doctor did cataract surgery and removed lens but did not replace with an IOL. I dont think i should use 66984 since we plan on Implanting IOL later, I cant use 65920 since we are not removing and Implant. Please help!
  7. Y

    Coding Question

    Can someone tell me what does it mean at the end of a chart note when it states "patient was seen in the absence of a Dr.?" The report shows cc, HPI, Physical exam, Procedure, and plan Do I need to bill an E&M code with when it states the patient was seen in absence of a dr?
  8. M

    Care plan oversight charges

    I feel so dumb. Does anyone know the location code for the care plan oversight charges? :o