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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 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?

    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?

    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

    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 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 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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