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    Wiki Hx of drug abuse

    Pt dx: hx of substance abuse. Under med hx it has cocaine, alcohol, opiod abuse (no use for 3 years - pt is being seen for eating d/o - substance abuse is secondary code). The codes come to current drug abuse codes. Is there a hx code for these that I can't find or is there a code that more...
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    Wiki Are warming fluids considered hydration?

    A pt comes to the ER for hypothermia due to Shapiro Syndrome. The pt was given 3 liters of warmed Normal Saline at 1000 mL/hr for 3 hours (3 liters total). Can we charge anything for this or is it bundled into the E/M? I initially wanted to charge hydration, but I don't think it meets that...
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    Wiki Nursing documentation of critical care

    When billing critical care for the facility do you use the Drs documentation of critical care time or does nursing have to document time seperately?
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    Wiki Bundling injections with fx reductions

    I originally put this in the Emergency Department group but I haven't heard from anyone yet. Can anyone here give me some guidance? A pt comes into the ER with a fx that needs to be reduced. He gets an injection for pain before the reduction. Can that be billed seperately or is that bundled...
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    Wiki Bundling injections

    A pt comes into the ER with a fx that needs to be reduced. He gets an injection for pain before the reduction. Can that be billed seperately or is that bundled into the reduction? What if he gets an IV with antibiotics?
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    Wiki Coding 'acute'

    If a dx states bronchitis and it states in the documentation that it is a new issue with sudden onset do you code acute bronchitis or bronchitis unspecified? Same with sinusitis and conjunctivitis?
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    Wiki Facility Critical Care

    We have just started doing the facility coding for our ER. I know that certain procedures are bundled into cc (cxr, vent management, blood gases, ets), but can they be billed seperately for the facility side? I always thought they were bundled, but in the CPT book it says "Facilities may...
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    Wiki Bedside Ultrasounds

    Our ER would like to start charging a facility fee for bedside ultrasounds. Does anyone know if there is a problem with that? The ER does own the machine if that makes any difference?
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    Wiki Nursing Documentation

    I have a BNP that does not have a payable dx documented by the MD. When the pt was triaged by the RN one of her complaints was SOB (the MD did not mention it) which is a payable dx. Can I use that?
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