Recent content by heatherwinters

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    Wiki Social History Screening

    If a nurse calls a patient a couple of days ahead of time to obtain social history, like smoking screening form, that should be documented as a telephone encounter on the date the information is obtained. It would not be documented on the same note as their upcoming visit as if it were...
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    Wiki Ros in hpi???

    Ros We have come accross this as well and are going to visit it in policy as a possible cloning issue. See the following taken from AHIMA: [/LIST]Source: Garrison, Susan E.. "Expert E/M Chart Auditing." 2008 AHIMA Convention Proceedings, October 2008.
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    Wiki AMA accepted coding changes for Psych

    Psychotherapy Time in New York State There does not seem to be a clear consensus in terms of the time element of the new psychotherapy codes in New York State. The NGS LCD L26895 indicates they will accept rounding of time to the nearest code but does not accurately reflecting the ama errata...
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    Wiki Additional Conditions

    I am looking for official guidance on billing for additonal icd-9 codes. I often see where providers list problems in their assessment only (example: using 250.00 then ordering an A1C) but did not list Diabetes in HPI or exam as an issue for that day. If a provider only lists a condition in...
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    Wiki 97597 vs E/M

    Thank You Thanks :)
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    Wiki 97597 vs E/M

    I work for an FQHC. A patient came in for evaluation of a bulla that had started to drain that day. Our PA documented 1 HPI, 1 ROS and the documentation in history of coexisting conditions. Provider performed problem focused exam - Vitals - General - Skin. He documented size of bulla...
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    Wiki 790.21

    If a patient had previous abnormal glucose levels but now the lab values are normal, can a clinician continue to use the 790.21 code in his assessment to justify further follow up? My thought is no. You must code based on what you know to be true at the time of reporting and currently the...
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    Wiki ICD9 CM and HTN Question

    Coding for htn See this article in For the Record http://www.fortherecordmag.com/archives/042312p28.shtml
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    Wiki Ny medicaid managed care - fidelis

    New York State's new managed care provider FIDELIS does not cover family planning services. If a patient with FIDELIS is seen for family planning, you are to bill it to Medicaid. This is fine for stand alone services like depo shots etc, but it's confusing when you treat more than one condition...
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    Wiki Annual Physical labs for Medicare patients

    Medicare Screening Labs If you look at Medicare's Quick Reference Information for Preventive services, they list specific codes that should be used for screening lab coverage. For example for screening lipid panel, cholesterol, lipoprotein, triglyceride Medicare states they want you to report...
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    Cpt codes: 82270, 82271, 82272

    82272 vs 82270 This is a question I have researched as well. According to CPT manual 82270 occurs when patient was provided 3 cards or single tripe card for consecutive collection. This does not occur when an occult stool is performed for screening in the office and a single specimen is...
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    Wiki Behavioral Health Cdoing-supporting documentation

    Coding for Mental Health I too work for a multispecialty practice and one of the services we offer is mental health. I have access to these records. We do have some staff who are restricted from seeing these types of notes but since my job deals specifically with coding based on documentation I...
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    Wiki POS 22 vs POS 11

    Pos Check out this article by the AAPC http://news.aapc.com/index.php/2009/10/pos-codes-do-you-know-where-your-doctor-is/
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    Wiki Cpt 90801

    90801 According to a recent training I attended you can bill one 90801 per provider (linked to tax ID number) per condition (icd-9), per setting, per duration (for Medicare duration is 12 months).
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    Wiki Blood Draw

    Blood Draws Patient should be placed on the schedule and a progress note in the EMR should be documented by the medical staff that drew the blood. Minimum documentation should include a reference to the original order, the site of the blood draw and how the patient tolerated the procedure...
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