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  1. pclaybaugh

    Wiki CPT 96127

    Another tidbit, for ADHD – this can be counted more than once if completed by different parties (e.g., parents and teacher), scored and documented by the provider.
  2. pclaybaugh

    Wiki H&P visit vs Comprehensive visit

    Please supply more context to the question. History and Physical, a component of an E&M, is the most formal and complete assessment of the patient and the problem and should be in most encounters. The E&M Guidelines is a great place to start.
  3. pclaybaugh

    Wiki Additional Dx Codes

    Thanks in advance for any answers. Patient is seen for back pain due to a fall, injected with Toradol. The diagnosis codes are clear but only used one diagnosis code. I am inclined to suggest the provider also add the Dx codes that were addressed (bold font). Happy to accept any input. The...
  4. pclaybaugh

    ED Workload Credit

    Hoping for some expert advice on good documentation to give the hardworking staff in the ED credit for their cognitive workload. Assume the symptoms the patient presents with are not active and there are no findings. Say 5 labs were ordered and counseling was completed for return precautions...
  5. pclaybaugh

    Wiki Counseling patient on options for pregnancy

    Hi, as you state the patient isn’t sure, perhaps leave off the Z-code for the unwanted pregnancy. This appears to be a confirmation of pregnancy visit, so Z32.01 seems appropriate.
  6. pclaybaugh

    Wiki Assistance with Hysterectomy Codes

    That’s a great tip. Thanks!
  7. pclaybaugh

    Wiki Assistance with Hysterectomy Codes

    Hello, many thanks, I will take a closer look. I have just found a Coding Clinic to help me along.
  8. pclaybaugh

    Wiki Assistance with Hysterectomy Codes

    Greetings, I code mostly OB deliveries and am revisiting Gyn Coding and have the following op report. Forgive the length. I have coded this with 58552. Please, am I missing something? A sterile speculum was placed in the patient’s vagina and the cervix was visualized. A single tooth tenaculum...
  9. pclaybaugh

    Wiki OB code sequencing - we're having a debate

    Well. just back into coding OB, but I place the condition codes just below those as in example B. Thanks for posting this as a debate and look forward to others responses.
  10. pclaybaugh

    Wiki Audiologist

    Hello, I am going down the audiology rabbit hole as well. Am reading an article as follows: https://www.audiologyonline.com/articles/evaluation-and-management-code-use-11371 Perhaps this will be helpful in some way.
  11. pclaybaugh

    Wiki Wart or Lesion Count

    Thanks, agreed. Whilst the location is evident, the count is not specific, rather as stated with a click.
  12. pclaybaugh

    Wiki RESECTION KELOID EAR

    Looks like the code I would use except for the fact that the codes 11441 - 11446 are based on length. I don't think you need a RT modifier.
  13. pclaybaugh

    Wiki What needs to be done for 31231?

    Hi, this is the CPT Asst. take: Introductory Text Key Changes The introductory text was expanded to further define the components of a diagnostic nasal endoscopy. A complete diagnostic nasal endoscopy (31231) includes visualization of the nasal cavity interior, the middle and superior meatus...
  14. pclaybaugh

    Wiki Wart or Lesion Count

    Good morning, all the items were addressed other than the actual count of warts, lesions, etc. Hopefully an answer with guidance will be forthcoming. Many thanks for your response.
  15. pclaybaugh

    Wiki Wart or Lesion Count

    Hello again, Please weigh in on whether there is a requirement or recommendation to indicate exactly how many lesion/warts areremoved. I am looking at documentation that appears to have a click box, >15 for wart numbers treated. My thoughts are the an amount should be forthcoming in order to...
  16. pclaybaugh

    Wiki Chemical Peels, Epidermal and Dermal

    Greetings, I'm currently dermatology and looking at chemical peels. Is it prudent to ask the provider to note the depth, either dermal or epidermal for this procedure? The case that I'm looking at only has the code with the code descriptor next to it. In other words he probably just clicked the...
  17. pclaybaugh

    Wiki 96900/96910 difference

    Thank you so much for sharing this important article. I could not get to it without membership! It is members like yourself that makes this forum so valuable.
  18. pclaybaugh

    Wiki Auditing and CDI Manuals

    Greetings, recommendations for any books or manuals that are your go to when auding medical records.
  19. pclaybaugh

    Wiki Actinic Keratosis Conundrum

    Thank you, Karl! I appreciate the reply and the clear explanation.
  20. pclaybaugh

    Wiki Actinic Keratosis Conundrum

    Greetings Michelle, Thanks for the reply. I did look at this with fresh eyes and the provider did state the diagnosis, not just click the box. There was not a pathology report but I was told that this condition is diagnosible by sight.
  21. pclaybaugh

    Wiki Actinic Keratosis Conundrum

    I may be going down the rabbit hole…it’s late in the day and I might be overthinking, but here goes… A provider is documentation actinic keratosis and ICD guidelines state that a source is needed. This “source” is not documented. He has also coded 17000 as well as 17003. Past medical history...
  22. pclaybaugh

    Wiki DoD outpatient coding questioins...please help

    Are you referring to the subjective (SOAP) portion of the note?
  23. pclaybaugh

    Wiki Fowler Stephens Orchiopexy

    Then I am stumped.
  24. pclaybaugh

    Wiki Determining E/M Level

    Is the provider documenting the vaccination as given in the clinic? Then get the administration and the HCPCS code for the vaccine. I would not give a data point for recommending that the vaccination be given.
  25. pclaybaugh

    Wiki HPI Help

    When a patient presents with more than one complaint one can use the most descriptive for the HPI and the rest for the ROS. I was taught not not to mix the various complaints for the HPI. An extended HPI needs at least four elements. As an alternative, one can also comment on the staus of three...
  26. pclaybaugh

    Wiki Fowler Stephens Orchiopexy

    According to what I have read, this can bee coded as a bilateral procedure: 54692-50 - Laparoscopy, surgical; orchiopexy for intra-abdominal testis [GFP 90 days]
  27. pclaybaugh

    Wiki ?

    There is currently no CPT code for this type of removal or entrapment. Your only choice is to utilize the appropriate level of E&M code 99201-99215 with the, hopefully well documented, medical decision making driving the level. I realize a specific CPT for the removal was wanted. I liken it to...
  28. pclaybaugh

    Wiki ?

    Wow, I did not expect that... Try this code, S30.842A with W49.09XA and the appropriate external cause codes.
  29. pclaybaugh

    Wiki 51736 and 51798 After TURP

    Thanks so much for responding. The EM is for the urinary urgency and is justafible. I appriciate your help.
  30. pclaybaugh

    Wiki ?

    This calls for a query. Upon reading, it appears as though this is an injury. Was the patient using a grinder and cut him/herself in two places? Was a metal piece embedded in the shaft and had to be removed? If so, code the injury, cause of injury, activity, place of injury. The documentation...
  31. pclaybaugh

    Wiki 51736 and 51798 After TURP

    Good Morning, The patient underwent a TURP and is in the global period. The provider is billing a 51736 urine flow measurement and 51798 US Urine capacity during the global period. The documentation states a routine follow up and that the patient is satisfied with voiding pattern and flow...
  32. pclaybaugh

    Wiki eye skin tag/eye skin lesion

    I am researching this as well and found the following article: https://www.reviewofophthalmology.com/article/how-to-document-and-code-lesion-removal CPT manual contains instructions at the beginning of the section for Excisions / Destructions just above CPT 67800. It states: “Codes for removal...
  33. pclaybaugh

    Wiki Electrocautery for Hemangiomas

    Further Guidance I realize this is an old thread and the following guidance was not available when the original question was posted. As i had to research this very subject, the following may help the next member. CPT Asst October 2010 states: Codes 17106-17108 are specific to destruction of...
  34. pclaybaugh

    Wiki NCS without EMG for Carpal Tunnel, Code Comparison Limb?

    Well, I hope someone who has a good grasp (no pun intended) will chime in!
  35. pclaybaugh

    Wiki NCS without EMG for Carpal Tunnel, Code Comparison Limb?

    Greetings,I have read most of the NCS posts and see that most of these are done with an EMG. The code I come up with for this test is 95909 - Nerve conduction studies; 5-6 studies. I would like to know if the comparison hand is also counted, then the code should be 95912. Any feedback greatly...
  36. pclaybaugh

    Wiki Global FESS

    Greetings, I have been given the ENT clinic as an auditing responsibility. Please help me understand if certain separate procedures are part of the global package. The patient had a Functional Endoscopic Sinus Surgery and presents 1 week postop. The physician performs a nasal endoscopy to...
  37. pclaybaugh

    Wiki CPMA Study guide Question

    There are two schools of thought regarding this topic. One believes it may and should document and calculate E/M levels based on any two of these three components. Following the guidelines in the narrowest sense, choosing any two would claim to justify high levels of E/M service even though one...
  38. pclaybaugh

    Wiki past, family. social history areas

    No known drug allergies. I would say use it with the caveat of the advice given above.
  39. pclaybaugh

    Wiki examination organ system

    If you are using the 97 exam guidelines the ENTM has several bullets. External appearance of the ears and nose (overall appearance, scars, lesions, masses) Otoscopic examination of theexternal auditory canals and tympanic membranes Assessment of hearing Inspection of nasal mucosa, septumand...
  40. pclaybaugh

    Wiki Diag codes to be used with 99497 and 99498

    Please read the following article, in particularly the comments. While this information is not official, there is some good discussion. I read that the diagnosis codes should be the patients problems. As far as time is concerned, CMS says they are abiding by the CPT time threshold...
  41. pclaybaugh

    Wiki Advanced Care Planning-The new ACP

    Thanks for the many golden nuggets. An ACP provider education piece is currently a project that I am putting together. Unfortunately, as many have found out, the guidance is sketchy. I am under the impression Dx codes used are the patients problem diagnoses, e.g. COPD, ESRD, neoplasm, etc. and...
  42. pclaybaugh

    Wiki New vaccine code for 90646 ????

    Deleated Vaccine Codes What products are you using to vaccinate your patients.? For example we use Prevnar13 and Pneumovax, the codes for those are 90670 and 90723. The best advice would be to look at the product you use and research the product web site for coding and billing information...
  43. pclaybaugh

    Wiki Collection of plasma metanephrines

    While this is an older post, I thought I would do some research.83835 The test is performed to determine metanephrine or normetanephrine concentrations. The specimen is urine collected over a 24-hour period. Method is high performance liquid chromatography (HPLC). Metanephrine or normetanephrine...
  44. pclaybaugh

    Wiki Retrospective Audits

    Hi, we audit 350+ and exclusively do the retrospective audits and try to reach each provider annually. There are ad hoc audits that often come up and must be addressed immediately. We do reaudits, also retrospectively, as needed.
  45. pclaybaugh

    Wiki Happy coders day in florida!

    Happy Florida Coder's Day, then...yipee! Who knew and why aren't we promoting this a bit more. I wonder if the local chapters are aware. Incedently, where is the list of important medical coder dates?
  46. pclaybaugh

    Wiki looking to famliarize

    The books I purchased are Neurosurgery/Neurology coding companion 2013 as well as the 2015 Auditor's Desk Reference. Both are by Optum. They are helpful, but I have access to the coding companions and the CPT assistants as well. While I have learned a lot, there is something new that crosses my...
  47. pclaybaugh

    Wiki EEG and EKG

    From the CPT Assistant: According to the Cardiography guidelines, codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated. There must be a specific order...
  48. pclaybaugh

    Wiki Bursectomy

    Check 27062, Excision; trochanteric bursa or calcification.
  49. pclaybaugh

    Wiki L5 transverse process and iliac pseudoarthrosis injection

    Could you look at CPT 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) or CPT 64999 (Unlisted procedure, nervous system).
  50. pclaybaugh

    Wiki rickham reservoir reconnected cpt code

    Would codes 62230 for replacement and 62160 for procedure work?
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