Recent content by Evelyn Kim

  1. Evelyn Kim

    Wiki 99203 + 92071?

    Did you include any modifiers on the CPT codes? check out the TMPPM Vision and Hearing Services handbook, November 2022 section 4.3.8.3: "Modifier LT or RT must be included on the claim to identify the eye on which the service was performed". https://www.tmhp.com/resources/provider-manuals/tmppm
  2. Evelyn Kim

    Wiki Use of arrows in hand written documentation

    I am auditing charts for a provider who is still using paper charts. I seem to remember reading that the use of the up & down arrows in not acceptable, because there are multiple meanings for them. I can't recall where I read this. Does anyone else remember this? Your help is greatly...
  3. Evelyn Kim

    Wiki A little lost when no clear history points

    The only other possibility would be associated signs/symptoms since she stated there are no symptoms.
  4. Evelyn Kim

    Wiki Providing Medical Records for an Audit

    I would agree that a compliance officer needs to make the determination if it is a breach. That being said if it was an insurance company requesting the audit, such as for HEDIS, they should not have access to records that are not covered members of their company. In my capacity as manager...
  5. Evelyn Kim

    Wiki Medicaid Secondary and Billing No show Fees

    Generally, Medicaid does not allow billing for no show appointments. If Medicare does not allow the charges Medicaid can not be billed for the no show fee.
  6. Evelyn Kim

    Wiki Patients over Paperwork - audit question

    It is always best practice to be able to see the document being reference. In fact I just discussed this with a client because I had disallowed the AWV because the required personal history form was not attached to the visit, among other findings. In addition the portion documented by...
  7. Evelyn Kim

    Wiki Referral Gifts

    As a fellow coder and a certified fraud examiner I would say be careful in giving gifts for referrals. It is important to avoid even the appearance of impropriety. It might be the better practice to send a thank you note and save the gifts for the holidays, then it is not tied to an activity...
  8. Evelyn Kim

    AAPC Forums: New Look, New Features

    Very pleasing to the eye. I like the report feature, this makes it easier to flag inappropriate behavior on the forums. Looking forward to getting to spend more time checking out more of the new features.
  9. Evelyn Kim

    Wiki How to become a proctor?

    I agree with the other coders, as an officer myself (secretary) our chapter starts a sign up sheet for the new year at our last meeting of the year. Our officers act as primary proctors, but gladly accept volunteers for the second proctor. Attend the next chapter meeting and reach out the the...
  10. Evelyn Kim

    Wiki Pediatric patients attend visits on their own

    I would be concerned that parents are sending children to the doctor with out an adult accompanying them. That being said, if the child is old enough to drive themselves then it is less of a concern than if they just drop the child off. If treatment is required who authorizes it if the child...
  11. Evelyn Kim

    Wiki Provider treated patients- did not complete notes and relocated

    Another physician can not sign the records, only the one who saw the patient can sign them. Unless signature authority has been granted to someone. I would recommend printing the records and mailing them, certified mail, to the NP and follow up with a letter giving a time frame for the records...
  12. Evelyn Kim

    Wiki Looking for guidance on co-worker matter

    I would be very concerned about coding directions being given by a non-coder. You are right the statements are too vague to be of use, remember the coder adage--If it is not documented it was not done. Of course if the person is someone who is a supervisor over you that might be an issue, but...
  13. Evelyn Kim

    Wiki Diagnosis Documentation

    The patient is out of the post-op period so the Z98.1 can not be a first listed DX. Z89.890 (other specified posprocedural states) followed by Z98.1 would be my recommendation since the visit is billable.
  14. Evelyn Kim

    Wiki Code CPT

    I would refer you to the E&M level guidelines. In example #1 this is a new patient, Problem focused history, Problem focused exam, and Straight forward medical decision making equals a level 1 new patient visit. In example # 2 This appears to be a well woman exam. The documentation supplied...
  15. Evelyn Kim

    Wiki changing level of E/M

    From a payer's point of view, this would not be acceptable documentation for changing the level of service. In fact it would raise red flags and could trigger an SIU investigation of the provider which could lead to refunds/recoupments and other sanctions. Addendums can be used by someone...
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