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  1. 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!
  2. 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...
  3. 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...
  4. 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...
  5. 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?
  6. 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...
  7. 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...
  8. 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...
  9. 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?
  10. 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...
  11. 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?
  12. 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-...
  13. 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...
  14. 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...
  15. 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...
  16. 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...
  17. 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...
  18. 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...
  19. Sarah Ann

    Wiki In order to code

    Question- someone comes into urgent care for shoulder pain. In the note - cc- here for shoulder pain. The patient has a history of hyperlipidemia, htn, --no mention of the treatment in the note. However there is a drug list in the EMR- I was told that if there is a statin the hyperlipidemia...
  20. Sarah Ann

    Wiki Urgent Care Chronic conditions (as secondary codes)

    Hello Does the following make sense in the urgent care setting? Coding managers are having us code only chronic conditions listed under the past medical history list(on the urgent care report) that match up to a medication on their list as secondary conditions even if no chronic conditions are...
  21. Sarah Ann

    Wiki Is this realy significant same day?

    Hello! I could be missing something (please feel free to let me know) This is an account from urgent care A Person came in for a tick bite: S40861A as admitting and principle (bite right upper arm initial encounter) W57XXXA secondary bitten arthropod-ext. cause. I coded the retained...
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