Recent content by Sarah Ann

  1. Sarah Ann

    Wiki Incidental finding and MDM.

    Thank you- Those were my original thoughts(to not work it into my MDM- but I just put the question out there thinking I was missing something because I couldn't figure out why I was asked to work this into my MDM.
  2. Sarah Ann

    Wiki Incidental finding and MDM.

    This is a pro. fee for an office visit. Yes the provider stated the radiologist noted an incidental finding of a thyroid nodule. The pt is being treated for a fx of the arm.
  3. Sarah Ann

    Wiki Incidental finding and MDM.

    Exactly. "It's inappropriate to report an incidental finding found on a rad. report when the finding is unrelated to the sign or sx, or the condition that necessitated the performance of the test for a patient being seen in the ER- the provider would need to clarify the finding was clinically...
  4. Sarah Ann

    Wiki Incidental finding and MDM.

    I'm sorry, I should have written out the documentation- in the MDM.- He's not treating it. Thanks though!
  5. Sarah Ann

    Wiki Office visit treatment options- grid

    If the pt is given a sling and a referral to Ortho. Where does that fall on the grid? I'm asking for treatment options- only. Thanks!
  6. Sarah Ann

    Wiki Incidental finding and MDM.

    I was asked why I didn't code an incidental finding (not treated addressed on the DOS According to the coding clinic 3rd Q2010 pp 8-9- incidental findings are not coded. I was told that does not mean you can't add it to the MDM. Any thoughts on how I would do this? I would think there would...
  7. Sarah Ann

    Wiki Data and risk "morbidity from additional testing/treatment"

    Can coders count data(1 xray ordered) then use it again to count as an element of risk? (office op visits) DATA order of 1 test xray- and again in the risk from additional testing/treatment because there's a risk to having xrays? This is without the provider stating this in the MDM- Is this...
  8. Sarah Ann

    Wiki Desperately help, seen this?

    A PCS code Extirpation of Matter from Right Lower Extremity Vein using Computer-aided Mechanical Aspiration, Percutaneous Approach, New Technology Group 7
  9. Sarah Ann

    Wiki A/P

    Pt comes in with a sore throat. Provider does an appropriate Exam and history. A/P- pharyngitis rapid strep neg. culture PCN 25mg/kg bid 10 days Is this enough to consider this medication management without the MDM? We're debating- I code this as medication management - even if there's no...
  10. Sarah Ann

    Wiki Liability

    Pt comes in with an acute uncomp. illness they do no tests- they tell the patient to take tylenol. With the new 2023 grid this is a 1. 99212 because there's nothing under OTC in CPT. 2. same scenario, but they give the pt an rx for cyclobenzaprine- but this one is a 99213 using the new 2023...
  11. Sarah Ann

    Wiki Liability

    I'm being told by management they(clinicians) don't want to document the risk, because there's a liability in doing that. Many of the clinicians document a differential diagnosis, there could be liability in doing that as well, so why is this more of a liability? It's something coders have to...
  12. Sarah Ann

    Wiki coding from radiology reports in ED

    The treating provider is the only source I use. Yes the radiologist is a physician, but they are not treating the physician. The ER provider diagnoses a fracture, the radiologist does not see one. I code the fracture- because that is what the examining provider is stating the dx on that DOS...
  13. Sarah Ann

    Wiki Liability

    (MDM encounters) Has anyone encountered clinicians unwilling to state the overall level of risk(as it is defined in Cpt) due to liability?
  14. Sarah Ann

    Wiki I am really questioning this

    I know we can count things offered to the patient like offered oxycodone for the patient's pain, but they refused. Xray and ct also offered- Yes I count those as well. I was just giving a hypothetical of a patient presenting with an acute uncomplicated/ illness or injury- 1 xray (ordered), no...
  15. Sarah Ann

    Wiki home exercise program- level for Risk

    Can I just say this- the 2023 E/M "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established...
See more
Top