Search results

  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...
  16. Sarah Ann

    Wiki I am really questioning this

    All it takes is the provider taking the entire (individual)patient's medical conditions into consideration- the risk of treatment is a moderate(risk of disease from treatment) level with treatment with Tylenol because the patient has CKD- I think this is what they want in 2023- reading under...
  17. Sarah Ann

    Wiki I am really questioning this

    Let's say a patient comes in with a knee injury, they do an xray (just order not independent review) find an effusion tell the patient to take Tylenol. Using the 2023 table I get a level 2, because there are no treatment options (even NGS has said there are no blanket rules for OTC, or they...
  18. Sarah Ann

    Wiki I am really questioning this

    E/M leveling requires the physician state the risk rather than coders picking a treatment option from the coding table, because it's ultimately up to the provider to make that decision. So, the AMA states we have to use the updated 2023 table- there are no treatment options like in the 95-97...
  19. Sarah Ann

    Wiki I would not give credit for this as Prescription Rx Mgmt. Just checking... agree ?

    I've had this scenario as well. The provider should state what the risk is for a patient taking a one time dose of an rx drug in a healthcare setting. I don't consider it medication management, but they also don't say there's a moderate risk of disease or death, because______________. OR it's...
  20. Sarah Ann

    Wiki level for treatment options

    Using the new MDM table. Those are examples only. There are no examples under minimal or low- an explanation by the AMA- the pt could have a disease that interacts with taking an OTC- The reason the table is "empty" they want the clinician to use their training and experience to decide what the...
  21. Sarah Ann

    Wiki risk of disease/mortality (of treatment)

    An outpatient comes in with a sore throat, they do a rapid strep- it's negative- the provider dx's viral pharyngitis. I have one acute uncomp. illness or even a minor problem. Tells patient to take tylenol. I get a level 2. The new table has nothing at all for OTC drugs.- They (AMA) explain...
  22. Sarah Ann

    Wiki Mod. 25

    I know we can add data points in the E/M for things that were considered- but if a patient comes in for a laceration the provider repairs the lac. - in the MDM- "patient doesn't think it hit bone, declines x-ray(assuming the provider asked the patient here) Does this in itself justify a...
  23. Sarah Ann

    Wiki Repeat EKG- tech. error

    I've come across charges for a repeat ekg- It was repeated because they didn't place all of the leads. 2 ekg's are entered- I don't think both of these should be charged even with a modifier. Am I correct?
  24. Sarah Ann

    Wiki Creating a note from memory🤔

    I coded it, I was just wondering if it met the the face to face on the DOS requirement. I wasn't questioning the provider. Thanks!
  25. Sarah Ann

    Wiki Creating a note from memory🤔

    Let's just say our policy is to follow CMS guidelines. I have some reports that are not finalized (the encounter documentation is absent) we're talking like more than a month. I'm hoping they(providers) keep written notes, but honestly I really don't think they do (IMHO). I had a provider...
  26. Sarah Ann

    Wiki Medical nec./compliance

    No but sometimes You'll find non- covered tests for office visits.
  27. Sarah Ann

    Wiki Medical nec./compliance

    Yes, I should have clarified, it's for the professional E/M encounter. It makes sense to look at orders for anc. services.
  28. Sarah Ann

    Wiki Medical nec./compliance

    We are being told by management it is OK to use orders, results and prior office visits for a covering diagnosis for med. necessity. As far as I know we can only use the date of service and provider documenation. Which is correct?
  29. Sarah Ann

    Wiki CT pasted into the encounter note (MDM)

    We have a provider that pastes the rad. report into the MDM- and that is it to me it's not their MDM- THEN there is no final diagnosis- just the report. I don't think we should report the findings from the report. The provider documenting the(professional) E/M should render a final diagnosis-...
  30. Sarah Ann

    Wiki Patient Left Without Seeing Physician

    How about when the pt is NOT and emergency department patient? On the facility side can we bill for triage? I have read CMS has stated that ED's can bill for this, but what about office visits 99212-99215 (urgent care a stand alone)I'm just looking for info. that states we can or cannot bill...
  31. Sarah Ann

    Wiki billing for op facility- for triage

    Facility billing for patients that leave without being treated. My understanding is that the emergency dept. can bill for triage if the pt leaves before treatment. However that same guidance is not issued for urgent care clinics (99212-99215 codes we use for uc). For example the pt comes in...
  32. Sarah Ann

    Wiki Documentation requirements

    AHA CC-1st quarter 2012- narrative diagnosis in the documentation- as opposed to an alpha-numeric code picked from a drop down or pick list.
  33. Sarah Ann

    Wiki I'm having a hard time explaining

    This is for professional outpatient coding by the way (which are stand alone encounters).
  34. Sarah Ann

    Wiki I'm having a hard time explaining

    I was offering suggestions for documentation. For instance if they say only pt has a history of this that and the other- nothing else , mentioned on the DOS I suggested even if the pt is here for an arm injury, and the provider only mentions histories without treatment, monitoring etc we can't...
  35. Sarah Ann

    Wiki I'm having a hard time explaining

    We share the same EHR with other practices. I was informed that everything from the EHR is considered documentation because the physician signs the final encounter note, this includes problem lists, medication lists info. that nurses collect (not BMI, or pressure ulcer stages etc.). Nothing on...
  36. Sarah Ann

    Wiki New EM guidelines more Complicated

    Has it gotten easier? I'm sending this from May, 2021.
  37. Sarah Ann

    Wiki Coding Strep Cellulitis

    I code the site of the cellulitis then the bacteria or virus.
  38. Sarah Ann

    Wiki subclinical hypothyroidism

    I use E02
  39. Sarah Ann

    Wiki Lab order

    A pt. comes in for knee pain- In the HPI, exam, assessment/plan there is only documentation related to the knee pain. Denial for a covid 19 test because the Z code was missing. It was missing because there was no mention anywhere in the encounter HPI, exam, MDM assessment/plan that they were...
  40. Sarah Ann

    Wiki Updated COVID ICD 10

    LOL- same here! I see it the way you do! S& SX- no documentation at all in the note of exposure(patient denies exposure) and no documentation(meaning in the provider's note) of suspicion. I don't feel I can use the Z20.828 code. And the encounter is not for Covid screening- just I'm sending a...
  41. Sarah Ann

    Wiki CRC documentation question

    We don't pull anything off the problem list (I code urgent care accounts). They could come in for a finger laceration--but the problem list follows them from their primary care phys. office. I would think it needs to be firstly mentioned by the provider in the note during that(face to face)...
  42. Sarah Ann

    Thank you.. can I send a couple of questions about documentation a little later?- I'm working...

    Thank you.. can I send a couple of questions about documentation a little later?- I'm working about 10 hours today. You can answer of course when you have time.
  43. Sarah Ann

    I'm currently studying CRC- I do have questions here and there- would you be willing to help?

    I'm currently studying CRC- I do have questions here and there- would you be willing to help?
  44. Sarah Ann

    Wiki CRC documentation question

    It could be me. One of the questions I have is regarding conditions that we can always code in the absence of provider documentation-- what? Here's an example of one of the modules- HPI Mr. Jones presents today for follow up to his recent visit for anginal episodes. We started him on Ranexa...
  45. Sarah Ann

    Wiki Conflicting info.? OR...

    It could be me. One of the questions I have is regarding conditions that we can always code in the absence of provider documentation-- what? Here's an example of one of the modules- HPI Mr. Jones presents today for follow up to his recent visit for anginal episodes. We started him on Ranexa...
  46. Sarah Ann

    Wiki Module Review Exam - CRC

    If I remember correctly- about 25- I think some have 50- the first few chapters.
  47. Sarah Ann

    Wiki MDM - Prescription Management

    You are correct- the duration of the RX does not have bearing on the complexity- treatment options RX drug management-mod. mdm.
  48. Sarah Ann

    Wiki The NOTE and the EHR

    Urgent care coding-usually people are presenting with a simple problem- sore throat, rash, laceration etc. The EHR- most of the medications and conditions have been addressed by their primary, but because we use the same EHR the info. surrounding the "note" follows the patient from visit to...
  49. Sarah Ann

    Wiki When to/not code from medical history

    My example- this is more in line of what I feel the documentation should be- CHF stable-will continue lasix and ACE inhibitor with the same dose-no changes.
  50. Sarah Ann

    Wiki When to/not code from medical history

    Honestly I get that a lot- I was told since the drug list and the disease list show up with the (encounter) note the provider is authenticating the information. Well that's great, but I think it has to be in the narrative. The 3rd of 4th quarter 2019 coding clinic gives an example- of how the...
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