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blaymon

Recent content by blaymon

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Wiki Point-of-care-ultrasound

Does anyone have a POCUS chart audit form? I am working with a client to audit provider's POCUS notes and I am having a difficult time finding a template online. Much appreciated!
- blaymon
- Thread
- Apr 25, 2024
- Replies: 0
- Forum: Medical Coding General Discussion
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Wiki Is an in-office injection considered prescription drug management?

Not everyone will agree on this topic and that is okay. Providers are still managing these injectable medications in the office. We have to review the patient's chart for allergies, current medications for possible interactions, comorbid conditions and sometimes recent lab work before I order...
- blaymon
- Post #17
- Feb 2, 2024
- Forum: E/M
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Wiki E/M - acute uncomplicated vs acute with systemic symptoms

The key sentence in the definition of "Acute Illness With Systemic Symptoms" is; For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated...
- blaymon
- Post #4
- Aug 4, 2023
- Forum: E/M
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Wiki Independent Interpretation of Tests

Please help! I need clarification on Independent Interpretation of Tests. I have read the update but am still confused. As a provider, if I order an ankle x-ray and provide my own independent interpretation in the patient's note, this will count towards Category 2 Independent Interpretation of...
- blaymon
- Thread
- Jul 13, 2023
- Replies: 1
- Forum: E/M
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Wiki Why is this a level 4 visit?

Clinical Vignette #5- I question the fact they are saying this is an acute illness with systemic symptoms. The patient is a 3 y/o with right ear pain, mild rhinorrhea, and not sleeping well due to pain. Temp at home is 101.3F. Temp in the clinic is 100.4F. Does everyone agree this is an acute...
- blaymon
- Post #4
- May 25, 2023
- Forum: E/M
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Wiki What level of service?

My thoughts exactly. I appreciate your comments!
- blaymon
- Post #6
- May 24, 2023
- Forum: E/M
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Wiki Why is this a level 4 visit?

I brought this up in a thread a couple months ago and I would like to know your thoughts on why this is a level 4 visit. This is from the AMA Toolkit case #5, page 11. Please let me know what you think. www.ama-assn.org/system/files/steps-forward-documentation-coding-toolkit.pdf
- blaymon
- Thread
- May 24, 2023
- Replies: 5
- Forum: E/M
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Wiki What level of service?

This is a disagreement between a physician and myself. I told him this would be a level 3 visit. He thinks it is a level 4 visit due to fever.
- blaymon
- Post #3
- May 24, 2023
- Forum: E/M
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Wiki What level of service?

A patient is diagnosed with uvulitis and has a fever of 100.4F and a heart rate of 76bpm. Her voice is hoarse. POCT strep test is negative. A dexamethasone injection is given in clinic and the patient monitored for 30 minutes with improvement in symptoms. What level of service would this...
- blaymon
- Thread
- May 23, 2023
- Replies: 5
- Forum: E/M
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Wiki Complexity of data

It does help. Thank you, Christine!
- blaymon
- Post #3
- Apr 23, 2023
- Forum: E/M
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Wiki Complexity of data

The guidelines state: "Ordering a test may include those considered, but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test...
- blaymon
- Thread
- Apr 21, 2023
- Replies: 2
- Forum: E/M
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Wiki E/M Level

Looks like a moderate, level 4 complexity of data to me.
- blaymon
- Post #4
- Apr 21, 2023
- Forum: E/M
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Wiki Is an in-office injection considered prescription drug management?

I am a PA, CPC and CEMC. I have always considered an in office injection of medications such as Toradol, Zofran, Phenergan, Rocephin, and steroids as prescription drug management. What do others think?
- blaymon
- Post #6
- Mar 7, 2023
- Forum: E/M
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Wiki Asymptomatic patient for STI check- known exposure to Chlamydia

I am thinking level 4. Here's why: Moderate complexity of data- 6 labs ordered Moderate risk- prescription medication
- blaymon
- Post #2
- Feb 4, 2023
- Forum: E/M
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Wiki Asymptomatic patient for STI check- known exposure to Chlamydia

What would you code this office visit? Patient:23-year-old female (new patient) Chief Complaint: Concerns about sexually transmitted infections (STIs) after her ex-boyfriend tested positive for Chlamydia. History of Present Illness: Ms. Smith presents to the office today concerned about her...
- blaymon
- Thread
- Feb 2, 2023
- Replies: 2
- Forum: E/M

blaymon