Recent content by BS&SC

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    Wiki In-office procedure note

    5mm rigid hysteroscope was used, saline was used for distention. A specimen was sent to pathology. Note reads: pt in or iv sed given pelvic wnl labial lesion noted as well as whitish area periurethral dx scope place into uterine cavity using saline nl findings D and C done dilated #15...
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    Wiki Finding newborns in EPIC

    Thank you for that. I have seen the name come up, as you indicated. My dilemma is more that newborns often don't have the same last name as the mother.
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    Wiki Unlisted Codes x2 examples

    Sample 1: Immediately following a repeat elective c-section, the patient, with a history of myomectomy, had a subcutaneous inclusion cyst excised and a keloid scar excised. I have Z98.890 and O34.219 to work with for Dx. I am thinking 11400 (dependent on diameter with margins) for the keloid...
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    Wiki S2900

    Has anyone ever been reimbursed for the use of Robotic Assist during a hysterectomy (58571). Our office sends this through all the time and it never gets reimbursed. Is there any hope? On a separate note, provider A & B, both under same Tax ID, sent me a charge for a RATLH they did where one...
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    Wiki Finding newborns in EPIC

    I code for OBGYN and am new to EPIC. In Cerner, the demographics page lists the newborn under the mother with a hyperlink to the baby's page. From there I can find Circ information. In EPIC, I am having a terrible time finding any link at all. Even trying to find the baby's name is difficult...
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    Wiki Use of “we” for modifier 80

    I have a provider who has done many, many surgeries with an assistant. The Op note I received last week regarding the use of an assistant said it is “standard procedure on a pelviscopy with bilateral salpingectomy.” In documentation, this same provider uses “we” to describe what the assistant...
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    Wiki Documentation by one QHP by another QHP and resources

    I am pretty sure I know the answer to this, but I constantly doubt myself when I can't find some resource to back me up. 1) Can one provider document for another because "it was a busy night." Separate from that, I have another problem with a provider doing a 3rd degree laceration bedside, but...
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    Wiki Same Provider Group

    Provider A is doing a 58571 with S2900. As provider A realizes there are many adhesions on the right, she takes care of transecting and ligating on the left and calls in Provider B from same group. Provider B takes over at console and does LOA, colpotomy, removes cervix and uterus through...
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    Wiki ED agreement with Obstetrics

    So if my physician has in the A/P to admit, I can bill with the AI mod, correct?
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    Wiki ED agreement with Obstetrics

    I have been told by my manager that we have an agreement with the Emergency room that they will not charge the E&M for admissions when it is a patient of our practice, so that we can charge the initial inpatient using the hospital personnel's H&P. I have not seen this agreement and am hesitant...
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    Wiki Global CS w/ supracervical

    This involves two providers of the same practice: Patient establishes desire not to have blood transfusions before being taken in to have a C-section with possible placental accrete. C-section is completed but Provider A who sees abnormal placental adhesions (I think that was what the report...
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    Wiki Delivery notes

    I have a couple of physicians who rely on what I think is the auto-generated reports done by nurses/hospital people...?? I am in Cerner, btw. The physician's name is mentioned as the doctor doing delivery and there are notes on laceration and a continual thread of time-stamped things that occur...
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    Wiki Hysterosalpingogram (HSG) documentation

    I have two OBGYNs who think they can use the radiologists report for their procedure note. My understanding is that they cannot. They must do their own note with patient consent, narrative and outcome of procedure. Am I missing the mark here?
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    Wiki ED E&M to surgery

    Just had a similar one today. At her appt, the woman was found via US to have missed abortion. Patient went to the hospital for a D&C. Provider in same group did an H&P at the hospital and went over risks, etc, and gave the option of D&C vs misoprostol. Patient wanted D&C and was taken to...
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    Wiki ED E&M to surgery

    I have a provider who sends ED consults to me. My understanding is that a consult is not a consult if she is deciding during her E&M that the patient needs surgery, which means she is taking over the care. Is that correct? IF so, my next question is if this is not a consult, do I code an ED E&M...
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