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  1. J

    Wiki Dialysis patient admitted due to weather

    There is a patient who is going to be admitted from a nursing home who needs dialysis M-W-F. She has some medical needs, but is being admitted mainly because they want to be able to make sure she can get to dialysis due to impending weather (blizzard conditions - state issued no-travel...
  2. J

    Wiki Extended ER

    I have a scenario that I have never come across before so I want to get some input. Patient presents to ER on 1/6 for chest pain. Cardiac protocol followed. Patient was planned to be transferred out for higher level of care but no beds were available at any of the hospitals in the state. The...
  3. J

    Wiki Mode and Means of arrival not captured - can I send it through?

    I have an ER visit from July 26 where the nursing staff did not document the mode and means of arrival for the patient. We have always sent it back to the nurse as that is a facility requirement to have it documented. The nurse is no longer here. Normally they are able to look in the dashboard...
  4. J

    Wiki Inpatient Leave of Absence

    Patient has been at our facility for 6 weeks for IV medication and acute care of wounds. The patient has an appointment at an outside facility today. Patient will return to our facility this afternoon. How do we handle this? I know that we need to document the leave of absence as the outside...
  5. J

    Wiki Missing Discharge Summary

    I have a patient that was admitted for end of life care. I am aware of the rules that come with that for the bed charges, etc but I have some questions about other things. 1) Patient had toenails trimmed by nursing - this is included in what would be considered bed charges, correct? 2) Patient...
  6. J

    Wiki Diabetic Shoe Measuring

    We have a Nurse that does the measuring for shoes for diabetic patients. Normally, I would charge the A5500 "For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe" but the...
  7. J

    Wiki Flu Shot by Pharmacist

    When a flu shot is given by a pharmacist, how does that get billed? Can the administration be billed? And would it be submitted under the pharmacist or does a provider need to sign off on it? I am new to flu shots being given by a pharmacist versus given in a clinic by a nurse.
  8. J

    Wiki Sample preparation for outside lab

    Our lab collects and prepares several types of samples that get sent to an outside lab for processing. We DO NOT perform the actual lab test in our facility. We ONLY collect it and prepare the sample for testing. What CPT code should be used to report the collection and preparation?
  9. J

    Wiki Abnormal Fetal Heartrate, Antepartum

    What code would you use for a patient that is coming in for an ultrasound for an abnormal fetal heart rate? The code we found is O76, but that says complicating labor and delivery. This is antepartum.
  10. J

    Wiki What is the determination for high-risk?

    A common disagreement between the coders in our facility is when to use to the high-risk codes for prenatal care. For example, a patient who is 40 years old and has delivered 7 children, prior to this pregnancy, comes in for an OB visit. The doctor does not specifically state that it is a...
  11. J

    Wiki Modifier 58 or 77

    Patient came in on 8/19 with a previously drained right axillary abscess (10060 was performed on 8/15 by provider A). This lesion has almost completely healed. Provider B performed a 10060 on the same abscess. The previous incision was re-opened and the two abscesses were connected by...
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