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    Wiki Point-of-care-ultrasound

    Does anyone have a POCUS chart audit form? I am working with a client to audit provider's POCUS notes and I am having a difficult time finding a template online. Much appreciated!
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    Wiki Is an in-office injection considered prescription drug management?

    Not everyone will agree on this topic and that is okay. Providers are still managing these injectable medications in the office. We have to review the patient's chart for allergies, current medications for possible interactions, comorbid conditions and sometimes recent lab work before I order...
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    Wiki E/M - acute uncomplicated vs acute with systemic symptoms

    The key sentence in the definition of "Acute Illness With Systemic Symptoms" is; For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated...
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    Wiki Independent Interpretation of Tests

    Please help! I need clarification on Independent Interpretation of Tests. I have read the update but am still confused. As a provider, if I order an ankle x-ray and provide my own independent interpretation in the patient's note, this will count towards Category 2 Independent Interpretation of...
    • blaymon
    • Thread
    • Replies: 1
    • Forum: E/M
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    Wiki Why is this a level 4 visit?

    Clinical Vignette #5- I question the fact they are saying this is an acute illness with systemic symptoms. The patient is a 3 y/o with right ear pain, mild rhinorrhea, and not sleeping well due to pain. Temp at home is 101.3F. Temp in the clinic is 100.4F. Does everyone agree this is an acute...
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    Wiki What level of service?

    My thoughts exactly. I appreciate your comments!
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    Wiki Why is this a level 4 visit?

    I brought this up in a thread a couple months ago and I would like to know your thoughts on why this is a level 4 visit. This is from the AMA Toolkit case #5, page 11. Please let me know what you think. www.ama-assn.org/system/files/steps-forward-documentation-coding-toolkit.pdf
    • blaymon
    • Thread
    • Replies: 5
    • Forum: E/M
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    Wiki What level of service?

    This is a disagreement between a physician and myself. I told him this would be a level 3 visit. He thinks it is a level 4 visit due to fever.
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    Wiki What level of service?

    A patient is diagnosed with uvulitis and has a fever of 100.4F and a heart rate of 76bpm. Her voice is hoarse. POCT strep test is negative. A dexamethasone injection is given in clinic and the patient monitored for 30 minutes with improvement in symptoms. What level of service would this...
    • blaymon
    • Thread
    • Replies: 5
    • Forum: E/M
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    Wiki Complexity of data

    It does help. Thank you, Christine!
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    Wiki Complexity of data

    The guidelines state: "Ordering a test may include those considered, but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test...
    • blaymon
    • Thread
    • Replies: 2
    • Forum: E/M
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    Wiki E/M Level

    Looks like a moderate, level 4 complexity of data to me.
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    Wiki Is an in-office injection considered prescription drug management?

    I am a PA, CPC and CEMC. I have always considered an in office injection of medications such as Toradol, Zofran, Phenergan, Rocephin, and steroids as prescription drug management. What do others think?
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    Wiki Asymptomatic patient for STI check- known exposure to Chlamydia

    I am thinking level 4. Here's why: Moderate complexity of data- 6 labs ordered Moderate risk- prescription medication
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    Wiki Asymptomatic patient for STI check- known exposure to Chlamydia

    What would you code this office visit? Patient:23-year-old female (new patient) Chief Complaint: Concerns about sexually transmitted infections (STIs) after her ex-boyfriend tested positive for Chlamydia. History of Present Illness: Ms. Smith presents to the office today concerned about her...
    • blaymon
    • Thread
    • Replies: 2
    • Forum: E/M
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    Wiki Independent Historian

    Quick question: Does the provider need to document an independent historian provided the history of present illness to meet the criteria for independent historian? Example: "Mom is with patient and providing the HPI." I know it can be inferred if the patient is 8 months old but probably a good...
    • blaymon
    • Thread
    • Replies: 1
    • Forum: E/M
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    Wiki Acute Illness with Systemic Symptoms

    I have been a PA for over 20 years and a CPC, CEMC for over 8 years. When I read the definition above, the important wording to me is "...may be treated to alleviate symptoms", I am thinking they are referring to a viral illness with fever, body aches, etc.. Perhaps the provider can treat the...
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    Wiki Acute Illness with Systemic Symptoms

    This is a tricky situation and I believe the provider's documentation will likely lead us to the correct answer. I recently found this coding toolkit on the AMA website. Please look at page 11: www.ama-assn.org/system/files/steps-forward-documentation-coding-toolkit.pdf If you look at the 5th...
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    Wiki seeing a patient on the job

    He should be able to bill for this service if he did a history, exam, and management but I am not sure how this conversation occurred. Did the employee say, "I have had sinus congestion and a cough for 5 days can you write me a prescription for an antibiotic?". Or did he actually document an...
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    Wiki E/M level

    MDM should almost always be moderate on any patient (new or est) with a new problem to provider and prescription drug management. Based on the note, I would code this a 99214.
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    Wiki E/M in the EHR

    With the EMR's I have worked with, at the end of each history section (meds, allergies, PFSH, ROS, problem list) we have to click a button stating we reviewed it. As far as I know, this meets the requirements for reviewing those sections.
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    Wiki Ros

    You are correct...the guidelines recognize 14 systems in the ROS. "All systems reviewed and are negative except what is noted in the HPI" is allowed per the guidelines.
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    Wiki Use of social history in E/M determination

    I would think you are correct. Smoking use would have to be clarified and then it could only be used as an element of the Social History.
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    Wiki Exam documentation - When a child is being seen for cough

    Regarding the sick child: As a provider, I agree on the Vitals, Head, Eyes, ENT, Cardio, Respiratory, Abdomen, Skin, and neuro. It would depend on the condition of the child if the musculoskeletal would be medically necessary. Without the musculoskeletal, you would still have 8 systems which...
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    Wiki HPI and Data Point question

    Question 1- you are correct. 95 guidelines now accepts three chronic/inactive conditions. Question 2- is a very good question. My thought is it can be counted as a review of old medical records as long as their is adequate documentation of the pertinent information. "EKG from January 2015...
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    Wiki What ROS

    It would fall under the Constitutional ROS.
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    Wiki Providers who are CPC and do coding consultations

    Are there any MD's, PA's, or NP's who are CPC's and have a coding consulting business? I have recently become a CPC and CEMC. I am thinking about becoming a coding consultant and would like to explore my options. Thanks, Brad PA-C
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